HIPAA AND COMPUTER INFORMATIONAL TECHNOLOGY
Computers have really revolutionized nursing care. We can access patient information within seconds or minutes. We can do bedside charting. The patient care plan is automatically compiled from physician orders and information entered by other nurses that is pertinent to the care of the patient.
Yet with the advances of CIT (Computer informational technology) nurses today need to be aware of the pitfalls of the accessing patient information on computers. When you put your password in and start to document or look up information on your patient every stroke of that keyboard is recorded in the patient’s record.
The only information you should be assessing is the patient that has been assigned to you or one that you are anticipating receiving from another unit. You should not be accessing information on any patient that you are not providing care for. That is considered a serious violation of HIPAA.
If you are asked by a physician to locate where a patient is, and you are not directly involved in that patients care, that is also considered a HIPAA violation. Physicians have computer codes and they must look it up themselves, and you can tell them why.
When a family member calls for information over the phone, you cannot give it even if they insist. You can politely say "I’m sorry that would be a violation of the patient's privacy law or HIPAA".
So what does that mean to you? Let’s suppose your best friend is a patient and you look up her/his lab work and test results. You print them out and view them. Later you visit your friend you mention their test results to them. Perhaps they haven’t heard the results of the tests from their physician or maybe they didn’t want anyone to know about their medical history. If this incident is reported by the patient, another individual or is discovered during a random audit then an investigation of the alleged violation will occur. Everything you did in the computer is documented and tracked.
So if you located your friend that is noted in the computer records. If you looked up medications, lab and/or test records a record is created. If you print out documents a record is created in the main server.
Finally, one last thing to remember to do, when you log into the computer make sure you log out. If someone comes along to access patient information under your log-in it appears that you have accessed that information. Click that button and log yourself off!
In today’s world of CIT it is very important that we take all necessary steps to avoid a HIPAA violation. NJNU cannot stress enough how vital this is to your employment as a nurse and protecting your nursing license.
