2.1 In most cases, for example, the physician is accountable. The accountability is for the protection of health records. However, the patients are responsible for protecting their documents since we are in an outpatient setting. We trust that our patients are responsible for maintaining records for follow-up reviews and future use.
2.3 All persons in this office who have access to personal information must adhere to the following information management practices:
Access is on a need-to-know basis.
We restrict access to authorized users.
Now, we will discuss contractual privacy clauses and agreements with third parties. This discussion includes security personnel, building maintenance personnel, and network technicians.
We protect the confidentiality of any personal information we access while providing patient care.
Thus, we collect, use and disclose personal information only to provide care and treatment or the administration of that care or for other purposes expressly consented to by the patient.
We adhere to the privacy and security policies and procedures of this office.
We educate and train staff on the importance of protecting personal information.
3. Collection of personal information
3.1 We collect the following personal information
Identification and contact information, including name and date of birth
Billing information, including state/district health insurance plan (health card) number and private medical insurance details, if applicable
Health information may include medical history and presenting symptoms
3.2 Limits on collection
We will only collect the information required to provide care, administrate the care provided, and communicate with patients. We will not collect any other information or allow the use of this information for other purposes without the patient’s express consent – except where authorized by law. These collection limits ensure that we do not collect unnecessary information.
4. Use of personal information
4.1 We use personal information collected from patients in this office for
Identification and contact – Emergency contact
To provide continuity of care: Historical record and Health promotion and prevention
Administration of the care provided: Prioritizing appointment scheduling and billing the provincial health plan.
Professional requirements: Risk or error management and Quality assurance (peer review)
Research studies and trials
5. Disclosure of personal information – I
5.1 Implied consent (Disclosures to other providers)
Unless otherwise indicated, we assume that patients have consented to use their information to provide care, including sharing the information with other health providers involved in their care. By seeking care from us, the patient gives implied consent for delivering that care.
We share relevant health information with other providers involved in the patient’s care. We could also share information that includes, and is not limited to, other physicians’ notes engaged in providing care.
5.2 The law sometimes requires the physician to disclose personal information without the patient’s consent. This law is only in limited situations. Such disclosures should be legally mandated and authorized. We include here some examples of these situations,
billing state health plans
reporting specific diseases
while reporting abuse (child, elder, spouse, etc.)
reporting fitness (to drive, fly, etc.)
by court order (when subpoenaed in a court case)
in regulatory investigations
for quality assessment (peer review)
for risk and error management, e.g., medical-legal advice
5.1 Disclosure of Personal Information – II
5.3 Express Consent (Disclosures to all other third parties)
The patient’s express consent, oral or written, is required before disclosing personal information to third parties for any purpose other than to provide care or unless authorized to do so by law.
Examples of situations that involve disclosures to third parties include, but are not limited to, third-party medical examinations and the provision of charts or chart summaries to insurance companies or lawyers who have obtained the necessary permission from responsible authorities.
Disclosure Log – Before disclosure to a third party, we shall make a notation in the file that the patient has provided express consent, or a signed patient consent form is appended to the file.
5.4 We use withdrawal of consent if
Patients can withdraw consent to share their information with other health providers at any time.
Patients also have the option to withdraw consent to have their information shared with third parties.
Moreover, if a patient chooses to withdraw their consent, the physician discusses any significant consequences concerning their care and treatment with patients.
6. Security measures
6.2 We include physical, technological, and administrative security measures.
6.2.1 We use the following physical safeguards
firstly, we use limited access to the office: monitored alarm system and deadbolt entry lock or keypad entry system
secondly, we use limited access to records: need to know basis and locked cabinets
finally, we use office layout/features: front desk privacy screens and soundproofing to ensure confidentiality
6.2.2 We use the following technological safeguards
firstly, we use protected computer access for patient health information, including passwords and user authentication
secondly, we use system protection, including firewall software and virus scanning software
thirdly, we use protected external electronic communications with separate Internet access
fourthly, we secure electronic record disposal. we safely dispose of computer hard drives and destroy all other removable media
finally, wireless connections that are separate from internet connections carrying patient data
7. Administrative Safeguards
Henceforth, we discuss office information management practices. Firstly, we provide access on a need-to-know basis. Thus, we restrict them only to authorized users
secondly, contractual privacy clauses/agreements with third parties included cleaning, security personnel, building maintenance personnel, and network technicians.
Thirdly, staff sign confidentiality agreements as part of their employment contract, and this confidentiality agreement or clause extends beyond the term of employment.
7.2 We protect personal information regardless of the format.
7.3 Thus, we communicate personal information and follow specific procedures,
In addition, we will take patient preferences concerning phone messages into consideration.
Unless authorized, we only leave our name and phone number on messages for patients.
In addition, we only receive digital faxes accessible by a secure sign-on
Also, we use pre-programmed numbers to ensure the proper recipient receives a fax
However, we do not use email for confidential messages, except if consented to by the patient. When patients initiate a personal statement by email, we assume that they have given implied consent for us to reply by email.
Thus, firewall and virus scanning software is in place to mitigate against unauthorized modification, loss, access, or disclosure
In addition, we send letters marked as “confidential” in a sealed envelope.
9. Record Retention
8.2 In addition, we use secure offsite record storage.
10. Procedures for secure disposal/destruction of personal information
At times, we use paper shredding to destroy paper records
Also, we physically destroy computer hard drives
In addition, we shred electronic media storage
9.2 Disposal log
We maintain a log before the secure disposal of a health record, with the patient’s name, the period covered by the destroyed paper, the method of destruction, and the person responsible for supervising the collapse – all standard procedures.
11. Access to information
10.1 Finally, patients do have the right to access their records promptly.
10.2 Thus, if a patient requests a copy of their records, we will provide it at a reasonable cost.
10.3 However, we will only provide access with the treating physician’s approval.
10.4 Thus, if the patient wishes to view the original record, one of our staff shall be present. Thus, this is to maintain the integrity of the form, and we could charge a reasonable fee for this access.
10.6 However, we follow specific guidelines or procedures in response to requests.
Acknowledge receipt of the request
Respond within a timely fashion not exceeding 30 days
12. Limitations on access
11.1 However, in minimal circumstances, denying that access to patient records is possible. This denial is only if providing access will create a risk to the patient or another person.
11.1.1 Accordingly, when we expect that the information seriously endangers the individual’s mental or physical health or safety, making the request or another person.
11.1.2 For instance, if the disclosure will reveal personal information about another person who has not consented to the disclosure. In this case, we separate only relevant data and censor other documents.
13. Accuracy of information
12.2 Nevertheless, the patient can request changes in their record on noticing inaccuracies. Also, we annotate the document or record it in such cases.
12.3 Finally, a physician’s authorization or approval is necessary for any notation