Sample Office Policies and Procedures

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Yes

  No

  N/A

Provider Services

Table of Contents

INTRODUCTION

1. MEDICAL OFFICE FACILITY STANDARDS

2. EMERGENCY PLANS/ DISASTER / SAFETY  Emergency Plan

3. OFFICE PROCEDURES  Reporting Violence, Abuse, and Neglect

4. MEDICAL RECORDS  Review of Test Results

Sample Office Procedures

Page 2 of 98

• January 2004

  Yes

  No

  N/A

5. INFECTION CONTROL

Infection Control

 Universal Precautions

 Bloodborne Pathogens Exposure

 Personal Protective Equipment

•  Hepatitis B Vaccination for Employees with Occupational Hazard

  Yes

  No

  N/A

 Post Exposure Evaluation and Follow-Up

 Hazard Communication to Employee

 Recordkeeping

 Communicable Disease Reporting

Implementation

 Reportable Diseases and Conditions

 Routine Procedures for Communicable Diseases

 Disinfection and Sterilization of Instruments

 Disposal of Patient Specimens

•  Sharps Disposal

  Yes

  No

  N/A

In-office Lab Tests

8. CLINICAL POLICIES AND PROCEDURES  Lead Screening

Page 3 of 98

• January 2004

  Yes

  No

  N/A

9. PHYSICIAN EXTENDER SUPERVISOR POLICIES  Physician/Clinician Agreement

10. OTHER  Medical Office Standards (Provider Site Policy & Checklist)

11. SAMPLE MEDICAL RECORD FORMS  Vaccine Administration Log

Page 4 of 98

1. MEDICAL OFFICE FACILITY STANDARDS

• Policy

  Yes

  No

  N/A

•  The medical office will be clearly identified on the exterior of the

  Yes

  No

  N/A

• building. The office will be identified near the street entrance and at

  Yes

  No

  N/A

• the front door entrance

  Yes

  No

  N/A

•  Facilities must be accessible to the physically disabled. Parking,

  Yes

  No

  N/A

• , ramps, hallways, waiting rooms, examining rooms, and

• restrooms will be clean and clear of debris

  Yes

  No

  N/A

•  Facilities must be readily accessible to the mentally disabled

  Yes

  No

  N/A

•  A plan showing exits for evacuation during an emergency must be

  Yes

  No

  N/A

• posted where it can be easily seen

  Yes

  No

  N/A

•  Office hours will be clearly posted

  Yes

  No

  N/A

•  Provide at least one examination room per provider on duty

  Yes

  No

  N/A

•  Make fire extinguisher(s) visible and conveniently located. Have the

  Yes

  No

  N/A

• extinguishers tagged and inspected annually

  Yes

  No

  N/A

•  Keep hallways, doorways, and exists free of any obstruction

  Yes

  No

  N/A

•  Keep trash contained and properly stored

  Yes

  No

  N/A

•  Do not store prescription pads, needles, or syringes in examination

  Yes

  No

  N/A

• rooms or within patient’s access

  Yes

  No

  N/A

•  On-site lab is CLIA certified, or if meets requirements has a certificate of waiver

  Yes

  No

  N/A

Page 5 of 98

2. EMERGENCY PLAN PROCEDURES

General Emergency Plans, Disaster, and Safety Procedures

• 1. Assess the type and extent of emergency, if possible

  Yes

  No

  N/A

• 2. Assure that all staff, patients, and visitors are evacuated to a safe place using emergency exits

  Yes

  No

  N/A

• 3. Assure personal safety

  Yes

  No

  N/A

• 4. Call (911/other number) and report disaster

  Yes

  No

  N/A

Page 6 of 98

EMERGENCY PLANS: Evacuation

• Policy

  Yes

  No

  N/A

• All employees shall be familiar with the disaster plans to assist in a safe evacuation of the building

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

• 1. An evacuation plan is required to be posted and accessible to patients and employees

  Yes

  No

  N/A

• 2. In the event of evacuation, all employees, including physicians, are required to assist in the safe evacuation of patients

  Yes

  No

  N/A

• 3. Exit signs are clearly posted

  Yes

  No

  N/A

• 4. Employees shall become familiar with the emergency exits and exit plan

  Yes

  No

  N/A

• 5. Evacuation of ambulatory patients. evacuation of the reception area

  Yes

  No

  N/A

• 7. When deemed safe, the Office Lead shall instruct employees in pairs to re- enter the building to perform the following tasks:

Page 7 of 98

EMERGENCY PLANS: Evacuation (cont’d)

•  Unplug all machinery and lock all cabinets containing medication;

  Yes

  No

  N/A

•  Turn off gas, water and electricity to the building;

  Yes

  No

  N/A

•  Survey the damage and look for any individuals who may not

  Yes

  No

  N/A

•  Retrieve the emergency drug box to provide emergency care for

  Yes

  No

  N/A

• have evacuated;

  Yes

  No

  N/A

• any individuals in need

  Yes

  No

  N/A

8. The Office Lead shall designate a person to call the Practice Management

• Director or Operations Manager

• 9. No front office or back office staff shall leave the parking area unless instructed to do so by the Office Lead, Practice Management Director or

  Yes

  No

  N/A

• Operations Manager

• 10. All providers are required to remain in the parking lot until dismissed by the Practice Management Director or Operations Manager

  Yes

  No

  N/A

Page 8 of 98

EMERGENCY PLANS: Earthquake

• Policy

  Yes

  No

  N/A

• All employees shall be familiar with the disaster plans to assist in the event of an an earthquake

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

• 1. Remain calm at all times. Reassure others to remain calm

  Yes

  No

  N/A

• 3. Staff and patients should not leave the building during the earthquake

  Yes

  No

  N/A

• 4. Stay away from windows

  Yes

  No

  N/A

• 5. If the earthquake appears to be minor (no damage noted, and all systems still functioning) continue working

  Yes

  No

  N/A

• 9. If a trapped individual is unable to be freed, immediately evacuate the individual

  Yes

  No

  N/A

Page 9 of 98

• 10. Do not re-enter a damaged building unless instructed to do by emergency

  Yes

  No

  N/A

• Note: Earthquakes are usually followed by a series of smaller, yet potentially possible injury

  Yes

  No

  N/A

EMERGENCY PLANS: Fire

• Policy

  Yes

  No

  N/A

• All employees shall be familiar with the disaster plans to assist in a safe evacuation in the event of a fire

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

• 1. If a fire occurs in your area, quickly evacuate all individuals who are in immediate danger. All office exits are to be marked and illuminated

  Yes

  No

  N/A

• Building exits are also to be marked and illuminated

  Yes

  No

  N/A

• 2. Keep all corridors clear of any equipment, supplies, or debris

  Yes

  No

  N/A

• 3. Fire exits should not obstructed or blocked at any time

  Yes

  No

  N/A

• 4. Close the door to prevent the fire from spreading

  Yes

  No

  N/A

• 5. If the fire is minor, use the fire extinguisher to put it out

  Yes

  No

  N/A

• 6. Once the fire is successfully extinguished, the Office Lead shall contact the

  Yes

  No

  N/A

• Fire Department to notify them of the incident

  Yes

  No

  N/A

• 7. If the fire is moving or spreading rapidly, the person finding the fire shall to call the Fire Department

  Yes

  No

  N/A

• 9. Upon evacuation, the front desk staff shall position themselves outside of all entrances into the building to prevent anyone from entering

  Yes

  No

  N/A

Page 11 of 98

Prevention Reminders:

• 10. The Office Lead shall take a formal count of all personnel to determine if all employees have evacuated

  Yes

  No

  N/A

• 11. Do not re-enter the building under any circumstances. coffeepot

  Yes

  No

  N/A

Page 12 of 98

• January 2004

  Yes

  No

  N/A

FIRE SAFETY POLICY

•  Proper fire safety procedures

  Yes

  No

  N/A

•  Fire exits

  Yes

  No

  N/A

•  Fire extinguishers (and sprinkler system)

  Yes

  No

  N/A

•  Fire zones and applicable space requirements

  Yes

  No

  N/A

•  Staff member requirements and responsibilities

  Yes

  No

  N/A

•  Steps to take in the event of fire

  Yes

  No

  N/A

•  Containment of fire and smoke

  Yes

  No

  N/A

• 1. All employees will participate in an annual fire extinguisher training class

  Yes

  No

  N/A

• A record of individual training is to be maintained in

  Yes

  No

  N/A

• 2. Fire drills are conducted by building management at least every c. Fire safety education training

  Yes

  No

  N/A

• 3. The office conducts or arranges for appropriate in-service of office personnel on fire safety and prevention topics

  Yes

  No

  N/A

Page 14 of 98

• Fire Extinguishers/Sprinkler System Policy

  Yes

  No

  N/A

Page 15 of 98

FIRE PREVENTION PROCEDURE

• Policy

  Yes

  No

  N/A

•  All office exits are marked and illuminated. Building exits are also

  Yes

  No

  N/A

• marked and illuminated

  Yes

  No

  N/A

•  All corridors are kept clear from equipment and supplies

  Yes

  No

  N/A

•  Fire exits are not obstructed or blocked at any time

  Yes

  No

  N/A

•  Electric cords and plugs are routinely checked for fraying

  Yes

  No

  N/A

•  All machines in the staff lounge are turned off at the end of the day

  Yes

  No

  N/A

• i.e., the coffee machine

  Yes

  No

  N/A

EMERGENCY PLANS: Power Outage

• Policy

  Yes

  No

  N/A

• Inform employees of the proper safety procedures in case of a power outage

  Yes

  No

  N/A

Procedures

• 1. In the event that the building loses power for more than five minutes, the

  Yes

  No

  N/A

• Office Lead and/or Switchboard Operator shall check the circuit breaker

  Yes

  No

  N/A

• 3. If the power is not restored by tripping the breaker, the Office Lead and/or

  Yes

  No

  N/A

• 4. The Office Lead shall call City of Bushnell utilities

  Yes

  No

  N/A

Page 17 of 98

EMERGENCY PLANS: Bomb Threat

• Policy

  Yes

  No

  N/A

• All employees shall become familiar with the disaster plans to assist in the event of a bomb threat, do the following:

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

• 2. The Police Department should be notified immediately by the Office Lead

• 3. The Office Lead shall inform the staff of the threat and ask each person to designated by the Office Lead

  Yes

  No

  N/A

• 4. If a suspicious object is discovered, the area should be sealed off and the

  Yes

  No

  N/A

• Office Lead notified

  Yes

  No

  N/A

• 6 If determined unsafe by the Office Lead (in conjunction with the Police premature delivery) on the consent form

  Yes

  No

  N/A

•  The above requirements apply only to elective

  Yes

  No

  N/A

• sterilization

  Yes

  No

  N/A

• - Immunizations: The federal National Childhood Vaccine Injury Act

  Yes

  No

  N/A

(42 U.S.C. 300aa-1 et seq.) requires that each health care practitioner,

• who administers one of several types of vaccines to any person, must

  Yes

  No

  N/A

• provide to that person (or if a minor, to the parent or legal guardian)

  Yes

  No

  N/A

• certain specified vaccine information materials regarding the benefits

  Yes

  No

  N/A

• and risks of the vaccine prior to its administration every time a vaccine

  Yes

  No

  N/A

• is administered. Vaccines for which this information must be supplied

  Yes

  No

  N/A

• are diphtheria, tetanus, pertussis, polio, measles, mumps, and rubella

  Yes

  No

  N/A

•  A concise description of the benefits of the vaccine;

  Yes

  No

  N/A

•  A concise description of the risks associated with the vaccine;

  Yes

  No

  N/A

•  A statement of the availability of the National Vaccine Injury

  Yes

  No

  N/A

•  A copy of the CDC Vaccine Information Statement for the

  Yes

  No

  N/A

• Compensation Program, and administered vaccine (VIS)

  Yes

  No

  N/A

•  The CDC VIS forms may be obtained in 14 languages from

  Yes

  No

  N/A

• the vaccine information materials order line of the DHS at

  Yes

  No

  N/A

• 9. Implied Consent: There are three (3) exceptions to informed consent – (1) the patient is mentally incapacitated and there is

  Yes

  No

  N/A

Sample Office Procedures

• Page 37 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

• OFFICE PROCEDURES: Consent Policies (Cont’d) was invoked will be documented in the medical record

  Yes

  No

  N/A

•  Patient requests not to be informed: If the patient or patient’s

  Yes

  No

  N/A

• representative asks that he/she not be informed of the risks

  Yes

  No

  N/A

•  Therapeutic privilege/physician discretion: In rare situations where a

  Yes

  No

  N/A

• physician can prove that under the circumstances it was reasonable

  Yes

  No

  N/A

• to believe that “the disclosure would so seriously upset the patient

  Yes

  No

  N/A

• that the patient would not have been able to dispassionately weigh

  Yes

  No

  N/A

• the risks or refusing to undergo the recommended treatment,” the

  Yes

  No

  N/A

• physician may withhold the information

  Yes

  No

  N/A

• 11. Consent of Minors: A written parental consent is required in order to treat a - Emancipated minor per court order – If the court order is obtained, the

  Yes

  No

  N/A

• DMV issues an ID card, which states that the minor is

  Yes

  No

  N/A

Sample Office Procedures

Page 38 of 98

• January 2004 medical record

  Yes

  No

  N/A

• - Minors on active duty in the US Armed Forces

  Yes

  No

  N/A

• - Minors receiving pregnancy care (treatment or prevention)

  Yes

  No

  N/A

• - Minors 12 years and older suffering from a reportable disease relating to

  Yes

  No

  N/A

• the diagnosis or treatment of that disease

  Yes

  No

  N/A

• - Married minor with marital proof (marriage certificate)

  Yes

  No

  N/A

Sample Office Procedures

Page 39 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Consent Policies (Cont’d)

 Pregnancy (Civil Code Section 34.5). In addition to the categories of

• minors who may consent for themselves, there are certain types of care

  Yes

  No

  N/A

• for which minors of various ages may give their consent to treatment

  Yes

  No

  N/A

• - Any minor of any age may consent to hospital, medical or

  Yes

  No

  N/A

• surgical care related to treatment or prevention of pregnancy,

  Yes

  No

  N/A

• except for sterilization procedures

  Yes

  No

  N/A

• - It is up to the minor to decide whether or not to involve her

• parents in these decisions

  Yes

  No

  N/A

• - If a parent requests a copy of the minor’s medical record, the

  Yes

  No

  N/A

• physician may make the birth control or pregnancy information

  Yes

  No

  N/A

• available only with the minor’s authorization

  Yes

  No

  N/A

• - The physician may provide the parent with a copy of all

  Yes

  No

  N/A

• information in the record except that pertaining to decisions on

  Yes

  No

  N/A

• pregnancy or birth control

  Yes

  No

  N/A

• (A practical hint would be to keep minor patient’s birth control medical record)

  Yes

  No

  N/A

•  Reportable Disease, Sexually Transmitted Disease (Civil Code Section 34.7)

  Yes

  No

  N/A

• - A minor age 12 or older may consent to hospital, medical or

  Yes

  No

  N/A

• surgical care required to diagnose and treat any infectious,

  Yes

  No

  N/A

• contagious, or communicable disease that is reportable to the

  Yes

  No

  N/A

• local health officer

  Yes

  No

  N/A

 Rape (Civil Code Section 34.8)

• - A minor age 12 or older may consent to hospital, medical or

  Yes

  No

  N/A

• surgical care related to the diagnosis and treatment of rape or

  Yes

  No

  N/A

• alleged rape

  Yes

  No

  N/A

•  The patient has the option to withhold or withdraw consent at any

  Yes

  No

  N/A

• time without affecting his or her right to future health care or

  Yes

  No

  N/A

Sample Office Procedures

Page 40 of 98

• January 2004 benefits to which the patient would otherwise be entitled;

  Yes

  No

  N/A

•  A description of the potential risks, consequences, and benefits of

  Yes

  No

  N/A

• telemedicine;

  Yes

  No

  N/A

•  All existing confidentiality protections apply;

  Yes

  No

  N/A

•  The patient is guaranteed access to all medical information

  Yes

  No

  N/A

• transmitted during a telemedicine consultation, and copies of this

  Yes

  No

  N/A

• information are available for a reasonable fee; and

  Yes

  No

  N/A

•  Dissemination of any patient-identifiable images or information

  Yes

  No

  N/A

• from the telemedicine interaction to researchers or others will not

  Yes

  No

  N/A

• occur without the patient’s consent

  Yes

  No

  N/A

• 13. Consent Distribution: A copy of the consent form must be given to the medical record

  Yes

  No

  N/A

• 14. Sample forms follow

  Yes

  No

  N/A

Sample Office Procedures

Page 41 of 98

• January 2004

  Yes

  No

  N/A

Emergency Plan Procedures

• 1. Assess the type and extent of emergency, if possible

  Yes

  No

  N/A

• 2. Assure that all staff, patients and visitors are evacuated to a safe place using emergency exits

  Yes

  No

  N/A

• 3. Assure personal safety

  Yes

  No

  N/A

• 5. Call (911/other number) and report disaster

  Yes

  No

  N/A

Sample Office Procedures

Page 42 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Emergencies and Consent

• Policy

  Yes

  No

  N/A

• A medical emergency is defined as a situation where “treatment appears to be deterioration or aggravation or the patient’s condition, or to alleviate severe pain”

  Yes

  No

  N/A

• When an emergency situation occurs, consent is necessary unless the patient is decision

  Yes

  No

  N/A

• This could be due to:

•  Injury of sudden illness

  Yes

  No

  N/A

•  Alcohol or drug intoxication

  Yes

  No

  N/A

•  Shock or trauma

  Yes

  No

  N/A

•  An underlying mental or physical disease or handicap

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

•  The patient’s death

  Yes

  No

  N/A

•  Severe disability

  Yes

  No

  N/A

•  Deterioration or aggravation of the condition

  Yes

  No

  N/A

•  Alleviate severe pain

  Yes

  No

  N/A

Sample Office Procedures

Page 43 of 98

• January 2004

  Yes

  No

  N/A

• OFFICE PROCEDURES: Emergencies and Consent (Cont’d) listening on the extension or speaker

  Yes

  No

  N/A

•  This should be documented on the consent form

  Yes

  No

  N/A

• 4. While there is no requirement that a provider obtain a consultation when because…

  Yes

  No

  N/A

Sample Office Procedures

Page 44 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Office Security

• Policy

  Yes

  No

  N/A

• It is office policy that all information contained in the medical record is private and released without the express consent of the patient. The office maintains a standard

  Yes

  No

  N/A

• Consent to Release Medical Records Form, which must be reviewed, understood and signed by patients before release of patient’s medical records (any part or entire record)

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

• 1. The medical record belongs to the physician/practice, and will not be made public

  Yes

  No

  N/A

• 2. Only the physician, clinical, and administrative staff, who have a specific need, shall have access to and handle medical records

  Yes

  No

  N/A

• 4. Information contained in the medical record is not to be discussed by or among employees, or with visitors unless there is a specific reason to do so

  Yes

  No

  N/A

• Such conversations are considered confidential

  Yes

  No

  N/A

• (Note: The office should state its policy for releasing HIV/AIDS and STD information contained in medical records. Policy should reflect state law.)

  Yes

  No

  N/A

• 5. All employees, consultants and contractors will be informed prior to data

  Yes

  No

  N/A

Sample Office Procedures

• Page 45 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

Sample

Affidavit of Confidentiality Statement Between and

• I, the undersigned, have read and understand that the

• Policy and Statement regarding the confidentiality of data and private medical activities and work with

• Signed Date

  Date

• Employee, Consultant, or Contractor

Sample Office Procedures

Page 46 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Sterilization

• Policy

  Yes

  No

  N/A

• To ensure instruments, supplies, and equipment are properly sterilized

  Yes

  No

  N/A

• Procedures for one year

  Yes

  No

  N/A

• 1. Monthly bacteriological tests will be conducted per policy; results will be

  Yes

  No

  N/A

• 2. Sterilizer thermometers will e checked and recorded daily; records will be

  Yes

  No

  N/A

• 3. Preventative maintenance on sterilizer according to policy; log will be kept

  Yes

  No

  N/A

• 4. Keep an effective separation of soiled or contaminated supplies and and dried. All jointed items will be opened and/or unlocked

  Yes

  No

  N/A

• Items designed for disassembly will be disassembled

  Yes

  No

  N/A

• - Items will be placed in appropriate covering/wrapping and

  Yes

  No

  N/A

• sealed with pressure/temperature sensitive indicator tape

  Yes

  No

  N/A

• - Items will be positioned in a steam sterilizer to enhance air

  Yes

  No

  N/A

• removal, allow free circulation and penetration of steam and

  Yes

  No

  N/A

• prevent excessive condensation

  Yes

  No

  N/A

Sample Office Procedures

Page 47 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Sterilization (Cont’d)

• - When items are removed, indicator tape will be checked to determine if

  Yes

  No

  N/A

• optimum exposure to steam

  Yes

  No

  N/A

• - Flash sterilization will be used for emergency sterilization only of clean

  Yes

  No

  N/A

unwrapped instruments and porous items

• - Sterilizer indicating thermometers will e checked and recorded daily

  Yes

  No

  N/A

• Records of thermometer charts will be kept for up to one year. (If the waived.)

  Yes

  No

  N/A

• - Monthly bacteriological tests will be conducted per test manufacture

  Yes

  No

  N/A

• frequency instruction, and records of results kept for up to one year. (3M Stearothermophilus. It is recommended by AMA, JCAHO, CDC DORN)

  Yes

  No

  N/A

• - Preventive maintenance of sterilizer will be performed according to

  Yes

  No

  N/A

• individual policy on a scheduled basis by qualified personnel, using the

  Yes

  No

  N/A

• manufacturer’s service manual for the sterilizer as a reference and a

  Yes

  No

  N/A

• maintenance record kept for up to one year

  Yes

  No

  N/A

 Cold Sterilization

• - Only activated high level disinfectant will be used; temperature 20

  Yes

  No

  N/A

• degrees C or higher and all items will be soaked for a minimum of 10

  Yes

  No

  N/A

• hours

  Yes

  No

  N/A

• - Disinfectant solutions will be kept covered and used in a well

  Yes

  No

  N/A

• ventilated area

  Yes

  No

  N/A

• - Cold sterilization applies to heat sensitive items (i.e., non-metal, non- such as Cytoscopes, stainless steel instruments, etc),

  Yes

  No

  N/A

• - Items will be thoroughly cleaned with soap and water, rinsed, and

  Yes

  No

  N/A

• dried. All jointed items will be opened and/or or unlocked. Items

  Yes

  No

  N/A

• designed for disassembly will be disassembled

  Yes

  No

  N/A

• - Items will be immersed completely in an activated high level

  Yes

  No

  N/A

• disinfectant solution such as Cidexplus that is at a temperature of 20

  Yes

  No

  N/A

• degrees C or higher, and soaked for a minimum of 10 hours

  Yes

  No

  N/A

• - Sterile forceps will be used to remove the items from the solution

  Yes

  No

  N/A

• - Items will be rinsed with sterile water and placed on a clean drape or

  Yes

  No

  N/A

• towel

  Yes

  No

  N/A

• - Only sterilization disinfectant solutions will be used, and will be kept

  Yes

  No

  N/A

• covered and used in a well ventilated area. An expiration date,

  Yes

  No

  N/A

• determined according to manufacturer’s written recommendations,

  Yes

  No

  N/A

Sample Office Procedures

Page 48 of 98

• January 2004 in use

  Yes

  No

  N/A

 Gas Sterilization

• - Applies to heat sensitive items (i.e., plastic items)

  Yes

  No

  N/A

• - Procedure must be performed in a well aerated area

  Yes

  No

  N/A

• - Environmental protection procedures will be followed

  Yes

  No

  N/A

• - Length of time for materials gas sterilized must be monitored

  Yes

  No

  N/A

• - Ethylene Oxide is an example of the type of gas used

  Yes

  No

  N/A

• - Provision must be made for safe handling and storage of medical gas

  Yes

  No

  N/A

• cylinders

  Yes

  No

  N/A

Sample Office Procedures

• Page 49 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Violence and Abuse

• Policy

  Yes

  No

  N/A

• 1. Health professionals will report suspected assault or abusive conduct

  Yes

  No

  N/A

• 2. A written report must be sent to the local law enforcement agency within two (2) working days

  Yes

  No

  N/A

3. Guidelines for Assessment

Sample Office Procedures

Page 50 of 98

• January 2004

  Yes

  No

  N/A

•  Minor lacerations, contusions, abrasions, fractures or sprains

  Yes

  No

  N/A

•  Injuries to the head, neck, chest, breasts, or abdomen

  Yes

  No

  N/A

•  Injuries during pregnancy, such as spontaneous abortions

  Yes

  No

  N/A

•  Multiple injury sites

  Yes

  No

  N/A

•  Chronic or repeated injuries

  Yes

  No

  N/A

•  Medical problems which indicate chronic or psychogenic pain

  Yes

  No

  N/A

•  Physical symptoms related to stress, anxiety disorders or

  Yes

  No

  N/A

• depression

  Yes

  No

  N/A

•  Chronic diseases such as asthma, seizures, arthritis, etc

  Yes

  No

  N/A

•  Multiple gynecological problems

  Yes

  No

  N/A

•  Frequent use of prescribed minor tranquilizers or pain

  Yes

  No

  N/A

• medications

  Yes

  No

  N/A

•  Psychiatric symptoms such as panic attacks, substances abuse,

  Yes

  No

  N/A

• inability to cope, feelings of isolation, suicidal tendencies

  Yes

  No

  N/A

•  Behavioral problems such as an appearance of fright, shame

  Yes

  No

  N/A

• or embarrassment

  Yes

  No

  N/A

Sample Office Procedures

Page 51 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Violence and Abuse (Cont’d)

• 4. Documentation of Abuse  A copy of the law enforcement reporting form

  Yes

  No

  N/A

• 5. Reporting suffering from it. If two or more persons are required to report the

  Yes

  No

  N/A

Sample Office Procedures

Page 52 of 98

• January 2004 her reporting duties by any supervisor or administrator

  Yes

  No

  N/A

•  There are no Penal Code statutes prohibiting verbal or mental

  Yes

  No

  N/A

• abuse per se or the psychological injuries arising out these acts, so

  Yes

  No

  N/A

• healthcare practitioners are not legally obligated to report such

  Yes

  No

  N/A

• cases

  Yes

  No

  N/A

Sample Office Procedures

Page 53 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Violence and Abuse (Cont’d)

6. Immunity

7. Penalties

• 8. Practitioner Domestic Violence Training

  Yes

  No

  N/A

• Legislature now requires that physician applicants for licensure who have they have training or coursework in spousal abuse detection and treatment

  Yes

  No

  N/A

• (Business and Professions Code 2089)

  Yes

  No

  N/A

Sample Office Procedures

Page 54 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Child Abuse/Neglect

• Policy

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

• 1. Signs and symptoms of abuse and neglect should be identified by the healthcare - Symptoms of suffocation or chemical abuse or indicators pointing to

  Yes

  No

  N/A

• Munchausen syndrome by proxy

  Yes

  No

  N/A

•  Sexual Abuse (includes both sexual assault and sexual exploitation)

  Yes

  No

  N/A

• - Bruises or abrasions to the inner thighs or external genitalia

  Yes

  No

  N/A

• - Attenuation or distortion of the hymen

  Yes

  No

  N/A

• - An alternation of anorectal tone

  Yes

  No

  N/A

• - Evidence of sexually transmissible disease

  Yes

  No

  N/A

• Pregnancy (although pregnancy alone is not sufficient to constitute the basis of a reasonable suspicion of sexual abuse)

  Yes

  No

  N/A

Sample Office Procedures

Page 55 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Child Abuse/Neglect (Cont’d)

•  Willful Cruelty or Unjustifiable Punishment of a Child

  Yes

  No

  N/A

Unlawful Corporal Punishment or Injury

•  Neglect (negligent treatment or maltreatment of a child by a child’s health or welfare is indicated or threatened)

  Yes

  No

  N/A

• - History of lack of appropriate well-child care

  Yes

  No

  N/A

• - Failure of a child to thrive

  Yes

  No

  N/A

• - Malnutrition, untreated medical conditions, poor hygiene,

  Yes

  No

  N/A

• rampant dental caries

  Yes

  No

  N/A

• - Behavioral indicators such as anxiety, depression, sleep

  Yes

  No

  N/A

• disturbances, enuresis, excessive masturbation, aggressive

  Yes

  No

  N/A

• behavior, excessive household responsibilities for age

  Yes

  No

  N/A

• including child care, poor school performance, discipline

  Yes

  No

  N/A

• problems and impaired personal problems

  Yes

  No

  N/A

•  Abuse in Out of Home Care (all cases of abuse as defined setting)

  Yes

  No

  N/A

• 2. Diagnosis

  Yes

  No

  N/A

• A thorough health assessment must be conducted by the physician, assessment on a child who may be a victim of abuse. The Office of

  Yes

  No

  N/A

Sample Office Procedures

Page 56 of 98

• January 2004

  Yes

  No

  N/A

• The following diagnostic process should be performed:

•  An assessment of the child’s immediate medical needs

  Yes

  No

  N/A

•  Compilation of the past medical and social history of the child

  Yes

  No

  N/A

• and family members

  Yes

  No

  N/A

•  Assessment of the plausibility of the history being provided in

  Yes

  No

  N/A

• light of pre-existing medical conditions

  Yes

  No

  N/A

•  Determination of how great a risk it would be if the child returns

  Yes

  No

  N/A

• home

  Yes

  No

  N/A

• 3. Reporting 300, Sacramento CA 95814

  Yes

  No

  N/A

Sample Office Procedures

Page 57 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Child Abuse/Neglect (Cont’d)

4. Immunity

5. Penalties

• Failure to report child abuse is a misdemeanor punishable by up to six months in failure to report the abuse

  Yes

  No

  N/A

6. Employee Statements

Sample Office Procedures

Page 58 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Elder and Dependent Adult Abuse

• Policy

  Yes

  No

  N/A

• To report physical injury or condition appearing to be the result of physical abuse, accordance with state laws, to the local law enforcement agency and Department of

Health. (Welfare and Institutions Code Section 15600-15659)

•  Abuse

  Yes

  No

  N/A

• Physical abuse, neglect, intimidation, cruel punishment, fiduciary abuse, immediate phone report is required to a 24 hour crisis line at the

  Yes

  No

  N/A

Physical Abuse

Sample Office Procedures

Page 59 of 98

• January 2004

  Yes

  No

  N/A

•  Sexual Assault

  Yes

  No

  N/A

 Physical Abuse Indicators

• - Multiple injury sites, bruises or welts that have a regular pattern

  Yes

  No

  N/A

• resembling the shape of an article which might have been used to

  Yes

  No

  N/A

• inflict the injury

  Yes

  No

  N/A

• - Burns that appear to be from a cigar or cigarette,

  Yes

  No

  N/A

• - Injuries to the head, neck, check, breasts or abdomen, contusions,

  Yes

  No

  N/A

• abrasions such as rope burns or lacerations especially on the

  Yes

  No

  N/A

• wrist, ankle, torso or extremities,

  Yes

  No

  N/A

• - Fractures, many times at different stages of healing, to the skull,

  Yes

  No

  N/A

• ribs, or long bones, Injuries to abdomen, kidney, bladder or

  Yes

  No

  N/A

• pancreas, intestinal perforation, ruptured liver, spleen or blood

  Yes

  No

  N/A

• vessels, spontaneous abortions resulting from injury to the

  Yes

  No

  N/A

• abdomen. Intramural hematoma of the duodenum or proximal

  Yes

  No

  N/A

• jejunum

  Yes

  No

  N/A

• - Chronic diseases such as asthma, seizures, arthritis, etc,

  Yes

  No

  N/A

• - Medical problems indicating chronic or psychogenic pain,

  Yes

  No

  N/A

• - Symptoms of suffocation and chemical abuse,

  Yes

  No

  N/A

• - Improbably explanation of injuries or major inconsistencies

  Yes

  No

  N/A

• between elder or dependent adult and caregiver’s injury etiology

  Yes

  No

  N/A

• description,

• - Changes in the elder or dependent adult’s behavior when the

  Yes

  No

  N/A

• caregive enters or leaves the room,

  Yes

  No

  N/A

• - Appearance of fright, shame or embarrassment, depression,

  Yes

  No

  N/A

• agitation, stress, inability to cope, panic attacks, feelings of

  Yes

  No

  N/A

• isolation, withdrawal, homicidal or suicidal tendencies,

  Yes

  No

  N/A

• - Frequent use of prescribed tranquilizers or pain medications,

  Yes

  No

  N/A

• - Risk factors such as caregiver substance abuse or historical family

  Yes

  No

  N/A

• violence

  Yes

  No

  N/A

Sample Office Procedures

Page 60 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Child Abuse/Neglect (Cont’d)

•  Sexual Abuse

  Yes

  No

  N/A

• - Bruises or abrasions on the inner thighs or external genitalia,

  Yes

  No

  N/A

• - Alteration in anorectic tone,

  Yes

  No

  N/A

• - Evidence of a sexually transmitted disease,

  Yes

  No

  N/A

• - Multiple gynecological problems,

  Yes

  No

  N/A

•  Fiduciary Abuse

  Yes

  No

  N/A

•  Neglect

  Yes

  No

  N/A

• Failing to care for an elder or dependent adult to the degree of care constitutes neglect. Indicators may include:

  Yes

  No

  N/A

• - Historical or current lack or delay of appropriate care,

  Yes

  No

  N/A

• - Failure to protect from health and safety hazards,

  Yes

  No

  N/A

• - Malnutrition, untreated medical conditions, weight loss,

  Yes

  No

  N/A

• - Failure to provide physical aids (i.e. eyeglasses, hearing aids, dentures and/or ambulatory assistive devices),

  Yes

  No

  N/A

• - Signs that the caregiver has been unwilling or unable to provide

  Yes

  No

  N/A

• assistance with daily living skills (i.e., poor hygiene, lack of etc)

  Yes

  No

  N/A

•  Abandonment

  Yes

  No

  N/A

Sample Office Procedures

Page 61 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Child Abuse/Neglect (Cont’d)

•  Isolation

  Yes

  No

  N/A

• - Acts intentionally committed for the purpose of preventing, and that do

  Yes

  No

  N/A

• serve to prevent, an elder or dependent adult from receiving his/her

  Yes

  No

  N/A

• mail or telephone calls

  Yes

  No

  N/A

• - False imprisonment

  Yes

  No

  N/A

• - Physical restraining of an elder or dependent adult for the purpose of

  Yes

  No

  N/A

• preventing them from meeting with visitors

  Yes

  No

  N/A

• - Telling a caller or prospective visitor that an elder or dependent adult is

  Yes

  No

  N/A

• not present, or does not wish to talk with the caller, or does not wish to

  Yes

  No

  N/A

• meet with the visitor where the statement is false, is contrary to the

  Yes

  No

  N/A

• express wishes of the elder or dependent adult, whether he/she is

  Yes

  No

  N/A

• competent or not, and is made for the purpose of preventing the elder

  Yes

  No

  N/A

• or dependent adult from having contact with family, friends, or

  Yes

  No

  N/A

• concerned persons

  Yes

  No

  N/A

•  Dependent Adult

  Yes

  No

  N/A

• A person between the ages of 18 and 64, who has physical or mental admitted as an inpatient to a 24 hour health facility as defined in Section

  Yes

  No

  N/A

• 1250, 1250.2 and 1250.3 of the Health and Safety Code

•  Elder means any person 65 years of age or older

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

• 1. A thorough assessment must be conducted by the physician, which includes following diagnostic process should be performed:

  Yes

  No

  N/A

Sample Office Procedures

Page 62 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Child Abuse/Neglect (Cont’d)

•  An assessment of the elder or dependent adult’s immediate

  Yes

  No

  N/A

• medical needs,

  Yes

  No

  N/A

•  Compilation of the past medical and social history of the elder or

  Yes

  No

  N/A

• dependent adult and family members (if applicable),

  Yes

  No

  N/A

•  Assessment of the plausibility of the history being provided in

  Yes

  No

  N/A

• light of pre-existing medical conditions

  Yes

  No

  N/A

•  Determination of how great a risk it would be if the elder or

• dependent adult were to return to their living situation or

  Yes

  No

  N/A

• residence

  Yes

  No

  N/A

Medical Record Documentation

• Medical Record documentation, maintained by the health care practitioner, should include but not be limited to the following:

•  Name of abuse victim,

•  Date/time abuse became known,

  Date

•  Physical assessment/evaluation, location, extent and character of

  Yes

  No

  N/A

• injuries,

  Yes

  No

  N/A

•  Map of the location of the injuries on the abuse victim’s body,

  Yes

  No

  N/A

• documented at the time of the health care service,

  Yes

  No

  N/A

•  Name/identify of alleged abuser

•  Description of the abusive event or abuse victim complaints (in their own words),

  Yes

  No

  N/A

•  Medical and relevant social history of the abuse victim,

  Yes

  No

  N/A

•  Health practitioner follow up (i.e., reporting, etc)

  Yes

  No

  N/A

Reporting

• Reporting is required of physicians, nurses, pharmacists and all other medical instances of other types of abuse, including cases of mental abuse, fiduciary abuse,

  Yes

  No

  N/A

Sample Office Procedures

• Page 63 of 98

  Yes

  No

  N/A

• January 2004 that are necessary to avoid physical harm or mental suffering

  Yes

  No

  N/A

Telephone Report

•  The long-term care ombudsman coordinator (when the abuse is alleged to have occurred in a long-term care facility),

  Yes

  No

  N/A

•  State Department of Mental Health, State Department of

• Developmental Services, or to a local law enforcement agency

  Yes

  No

  N/A

• (when the abuse is alleged to have occurred in a state mental hospital or state developmental center),

  Yes

  No

  N/A

•  County Adult Protective Services Agency or County Welfare

  Yes

  No

  N/A

• Department (when the abuse is alleged to have occurred anywhere else)

  Yes

  No

  N/A

Report Requirements

• The report should include the name of the person making the report, the name, suspect elder or dependent adult abuse. The 24-hour toll-free number for the

  Yes

  No

  N/A

• Department of Aging Crisis Hotline is 800-231-4024

  Yes

  No

  N/A

• A written report must be completed within 48 hours of the telephone report, on a

  Yes

  No

  N/A

• California Department of Social Services form SOC341 entitled “Report of Suspected

• Elder or Dependent Adult Physical Abuse,” and mailed to the address indicated by protective services. This form is obtainable from the County Adult Protective

• Services Agency or the local long-term care ombudsman program

  Yes

  No

  N/A

Sample Office Procedures

Page 64 of 98

• January 2004

  Yes

  No

  N/A

OFFICE PROCEDURES: Reporting Child Abuse/Neglect (Cont’d)

•  The law provides that care custodians, health practitioners, or employees of

  Yes

  No

  N/A

• adult protective services agencies or local law enforcement agencies will not

  Yes

  No

  N/A

• incur either civil or criminal liability for any report they are required or

  Yes

  No

  N/A

• permitted to make under this law. However, any person who knowingly fails

  Yes

  No

  N/A

• to report, when required, an instance of elder abuse is statutorily guilty of a

  Yes

  No

  N/A

• misdemeanor punishable by a fine not to exceed $1,000, or imprisonment in

  Yes

  No

  N/A

• the county jail exceeding six (6) months or both. A healthcare practitioner may

  Yes

  No

  N/A

• also be liable in civil court for damages that occur if the elder or dependent

  Yes

  No

  N/A

• adult is further victimized because of failure to report the abuse

  Yes

  No

  N/A

• Endangered Adults Laws

  Yes

  No

  N/A

•  A local law enforcement agency takes custody of the endangered

  Yes

  No

  N/A

•  It is determined by the responding agency the adult is not

  Yes

  No

  N/A

• adult,

  Yes

  No

  N/A

• endangered,

  Yes

  No

  N/A

•  The responding agency takes other appropriate action to ensure

  Yes

  No

  N/A

• the safety of the endangered adult

  Yes

  No

  N/A

Sample Office Procedures

• Page 65 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

Employee Acknowledgement Form

•  Reporting is done to the following or to local Law

  Yes

  No

  N/A

• enforcement/Police:

  Yes

  No

  N/A

• - Adults (60+ years, living independently)

  Yes

  No

  N/A

• - Adults (18-59 years, living independently)

  Yes

  No

  N/A

Adult Protective Services

1725 Technology Dr

• San Jose, CA 95110

Adult Protective Services

591 N. King Rd

• San Jose, CA 95133

Hotline: (800) 414-2002

• - Adults (in RCH)

  Yes

  No

  N/A

• Fax: (408) 923-2134

  Yes

  No

  N/A

Long Term Care Ombudsman – Catholic Charities

2625 Zanker Rd., #200

• San Jose, CA 95134-2107

• (408) 944-0567 9am to 5pm

  Yes

  No

  N/A

• (800) 231-4024 after 5pm

  Yes

  No

  N/A

Sample Office Procedures

• Page 66 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

MEDICAL RECORDS: Requirements and Standards

• Policy

  Yes

  No

  N/A

• All providers shall maintain medical records in accordance with the most recent

  Yes

  No

  N/A

• National Committee for Quality Assurance (NSQA) standard. A manner that is maintains confidentiality

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

• 1. The medical record will be filed using a systematic method for easy retrieval, such as alphabetical or numerical filing, preferably color coded

  Yes

  No

  N/A

• 4. Medical records will be inaccessible to patients and other unauthorized confidential information and will protect confidentiality

  Yes

  No

  N/A

• 5. There is a medical record for each member seen by an IPA contracted chronologically

  Yes

  No

  N/A

• 6. All pages in the record will be securely anchored and all pages will be filed

  Yes

  No

  N/A

• 7. Each page in the record contains the patients name or patient ID number for patient identification

  Yes

  No

  N/A

• 8. Personal/biographical and demographic data included age, sex, address, telephone number, marital status, and is updated as appropriate

  Yes

  No

  N/A

• 9. A copy of a consent to treat form is maintained in the medical record

  Yes

  No

  N/A

Sample Office Procedures

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• January 2004

  Yes

  No

  N/A

• 10. The medical record will document all aspects of patient care, including use of ancillary services

  Yes

  No

  N/A

• 11. All entries are dated

  Yes

  No

  N/A

• 12. The author of all entries is identified, including title

  Yes

  No

  N/A

• 13. The records are legible, documented accurately, and in a timely manner

  Yes

  No

  N/A

• 14. Allergies and adverse reactions are prominently noted on the record

  Yes

  No

  N/A

• 16. A record of immunizations is documented for all age groups. For parents must be documented

  Yes

  No

  N/A

• 17. For Pediatric records (age 12 and under), there is a completed neurological milestones

  Yes

  No

  N/A

• 18. For members 12 years and older, there must be a notation concerning cigarettes, alcohol, substance use, and anticipatory guidance

  Yes

  No

  N/A

• 20. Identification of current problems and significant illnesses, medical record

  Yes

  No

  N/A

• 21. The reason for the visit is noted, i.e., the chief complaint (s)

  Yes

  No

  N/A

• 22. A history and physical examination with appropriate subjective and objective information must be obtained for the presenting complaints

  Yes

  No

  N/A

• 23. Appropriate vital signs are documented at each visit

  Yes

  No

  N/A

Sample Office Procedures

Page 68 of 98

• January 2004

  Yes

  No

  N/A

• 24. Diagnostic information and a plan of treatment for each visit are to be documented

  Yes

  No

  N/A

• 25. Treatments, procedures, and tests, including results are to be documented and consistent with treatment

  Yes

  No

  N/A

• 26. There is a specific follow-up date for a return visit or other follow-up plan for each encounter

  Yes

  No

  N/A

• 27. Referrals to specialty consultants and/or ancillary services are documented

  Yes

  No

  N/A

• 28. There must be evidence that there is continuity and coordination of care between the primary and specialty physicians

  Yes

  No

  N/A

• 29. Lab, pathology, and x-ray reports filed in the chart are to be signed or initialed by the provider signifying they have been reviewed

  Yes

  No

  N/A

• 30. Consultation and abnormal lab and/or imaging results have an explicit notation in the record for follow-up plans

  Yes

  No

  N/A

• 31. Discharge summaries, Emergency Department reports, Specialty weeks of service

  Yes

  No

  N/A

• 32. There must be evidence of that failed appointments are followed-up on

  Yes

  No

  N/A

• 33. Patient health education, recommendations, instructions, and referrals are to be documented

  Yes

  No

  N/A

• 34. Preventive services are to be evident and appropriately used

  Yes

  No

  N/A

• 36. If appropriate, a human sterilization consent form (PM330) will be filed in the patient’s medical record

  Yes

  No

  N/A

• 37. Initial health assessments and Child Health and Disability (CHDP) screenings must be documented

  Yes

  No

  N/A

Sample Office Procedures

Page 69 of 98

• January 2004

  Yes

  No

  N/A

• 38. A copy of the CHDP PM 160 form will be placed in the medical record (CHDP Providers only)

  Yes

  No

  N/A

• 40. Standardized forms for documenting prenatal care will be used. Forms (Comprehensive Prenatal Services Program [CPSP] Providers only)

  Yes

  No

  N/A

• 41. Adult medical records must be stored for seven years (7). Pediatric medical records must be stored until the child is 21 years of age (current State and

  Yes

  No

  N/A

• Federal requirements)

  Yes

  No

  N/A

Sample Office Procedures

• Page 70 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

MEDICAL RECORDS: Information Confidentially and Access to Records

• Policy

  Yes

  No

  N/A

• Procedure

  Yes

  No

  N/A

• 1. Active medical records are to be stored in one central medical records area that is accessible only to authorized personnel

  Yes

  No

  N/A

• 2. Only assigned personnel, responsible for the maintenance of medical records, will have access to medical records

  Yes

  No

  N/A

• 3. Contract practitioners/provider’s contracts will explicitly state expectations about the confidentiality of member’s information and records

  Yes

  No

  N/A

• 4. All staff with access to medical records must have a signed confidentiality agreement on file in the provider’s office

  Yes

  No

  N/A

• 6. Disposal of records will be done in a confidential manner (i.e. professional shredding)

  Yes

  No

  N/A

• 7. Unauthorized sharing of medical information is prohibited

  Yes

  No

  N/A

• 8. (SB 19) Providers are expressly prohibited from:  Negligent disposal of medical information

  Yes

  No

  N/A

Sample Office Procedures

Page 71 of 98

• January 2004

  Yes

  No

  N/A

•  Intentional sharing, sale or use of medical information for any

  Yes

  No

  N/A

• purpose other than to provide health care services to the

  Yes

  No

  N/A

• member, except as otherwise authorized

  Yes

  No

  N/A

• 10. A health care service plan or provider of health care may disclose medical under Civil Code Section 56.10(a) and Civil Code Section

  Yes

  No

  N/A

• 56.10(b)  For purposes of diagnosis or treatment of the patient. Civil Code

  Yes

  No

  N/A

Section 56.10(c)(1)

Sample Office Procedures

• Page 72 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

•  To an insurer, employer, health care service plan, employee

• benefit plan, governmental authority, contractor or any other

  Yes

  No

  N/A

• person or entity responsible for paying for health care services

  Yes

  No

  N/A

• rendered to the patient, to the extent necessary to allow

  Yes

  No

  N/A

• responsibility for payment to be determined and payment to be

  Yes

  No

  N/A

made. Civil Code Section 56.10(c)(2)

•  To an independent medical review organization and their

  Yes

  No

  N/A

• reviewers (AB2094), Civil Code Section 56.10(c)(4)

  Yes

  No

  N/A

•  Except to the extent expressly authorized by the patient or as

  Yes

  No

  N/A

• provided in Civil Code Section 56.10(b) and (c), no corporation

  Yes

  No

  N/A

• and its subsidiaries and affiliates shall intentionally share, sell or

  Yes

  No

  N/A

• otherwise use any medical information for any purpose not

  Yes

  No

  N/A

• necessary to provide health care services to the patient. (SB1903)

  Yes

  No

  N/A

Civil Code Section 56.10(d)

•  Further disclosure of medical information regarding a patient or

  Yes

  No

  N/A

• the provider of health care or an enrollee of a health care service

  Yes

  No

  N/A

• plan. (SB1903) Civil Code Section 56.10(e)

  Yes

  No

  N/A

•  Patients, attorneys, or representatives of the patient or attorney

  Yes

  No

  N/A

• receive a copy of the medical records only after presenting a

  Yes

  No

  N/A

• signed authorization from the patient or his/her legal

  Yes

  No

  N/A

• representative

•  The patient presents identification when requesting a copy of

  Yes

  No

  N/A

• their medical record

  Yes

  No

  N/A

•  With patient authorization, outside health care providers, Federal,

  Yes

  No

  N/A

•  With a subpoena, an officer of the Federal, State, or municipal

  Yes

  No

  N/A

• court may gain access to a patient’s records

  Yes

  No

  N/A

•  Agencies such as the FDA or other authorities that comply with

  Yes

  No

  N/A

• reporting requirements in Title 17 of the California Code of

• Regulations also may gain access to confidential information

  Yes

  No

  N/A

• - Any release of information in response to a court order or to

  Yes

  No

  N/A

• other authorized persons is to be reported to the patient

  Yes

  No

  N/A

• within five (5) working days

  Yes

  No

  N/A

• 11. Medical records are only released under the following conditions:

  Yes

  No

  N/A

Sample Office Procedures

Page 73 of 98

• January 2004

  Yes

  No

  N/A

• 12. Member records are available, whether or not authorized by the enrollee, to qualified personnel for the purpose of conducting scientific research

  Yes

  No

  N/A

• 13. For the purpose of sharing enrollee information with any organization with delivered in a timely fashion so to not impede continuity of care. (QISMC 3.6.4)

  Yes

  No

  N/A

• 17. Minors have the right to confidential services without parental consent

  Yes

  No

  N/A

• 18. All medical records released to authorized parties are legible documents

  Yes

  No

  N/A

Sample Office Procedures

Page 74 of 98

• January 2004

  Yes

  No

  N/A

• 21. All patient medical records obtained for use by the health plan or medical purposes are protected from disclosure

  Yes

  No

  N/A

• 22. Physicians may request a reasonable reimbursement for the cost of copying a member’s medical records

  Yes

  No

  N/A

• 23. Sample Medical Information Release Forms are found under “Medical

  Yes

  No

  N/A

Records: Confidentiality”

Sample Office Procedures

• Page 75 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

MEDICAL RECORDS: Confidentiality

• Policy

  Yes

  No

  N/A

• Medical records are kept confidential under the California statue “Confidentiality of

  Yes

  No

  N/A

• Medical Information Act, Civil Code §56 et seq. This Act prohibits disclosure of legal representative

• Procedure

  Yes

  No

  N/A

• 1. Members will have access to their medical information

  Yes

  No

  N/A

• 2. Medical information will not be disclosed without the consent of the member

  Yes

  No

  N/A

• 6. Members will be given the opportunity to consent to or deny the release of medical information, except as required by law

  Yes

  No

  N/A

Sample Office Procedures

Page 76 of 98

• January 2004

  Yes

  No

  N/A

• 7. Disclosure of patient medical records by a physician is permitted without patient authorization when authorized by law

  Yes

  No

  N/A

• 8. Disclosure of medical information will be given to the extent to secure responsible for payment for services,

  Yes

  No

  N/A

• 9. Physicians may request a reasonable reimbursement for the cost of copying a member’s medical records

  Yes

  No

  N/A

Sample Office Procedures

Page 77 of 98

• January 2004

  Yes

  No

  N/A

• MODEL LETTER TO A PATIENT WHO REQUESTS WITHHOLDING

OF INFORMATION FROM DISCLOSURE

• [Date]

  Date

CONFIDENTIAL

• Patient’s Name

• Address

• City, State Zip

Re: Release of Medical Information

Dear Patient:

• I am in receipt of both your general authorization for release of your medical records

  Yes

  No

  N/A

• (insert entity name) and of your request that certain information in the record not be

  Yes

  No

  N/A

• disclosed. I understand the need for confidentiality concerning the medical

  Yes

  No

  N/A

• information in your file. The principal California statute governing confidentiality of

  Yes

  No

  N/A

• medical information is the Confidentiality of Medical Information Act. Civil Code

• §56 et seq. Generally speaking, this Act prohibits disclosure of medical information

  Yes

  No

  N/A

• absent an authorization signed by the patient or the patient’s legal representative

  Yes

  No

  N/A

• Except as authorized by this statute and other relevant laws, I will not release first obtained your prior written authorization

  Yes

  No

  N/A

• However, you should be aware that if you refuse to permit disclosure of certain at the patient’s request

  Yes

  No

  N/A

Sample Office Procedures

Page 78 of 98

• January 2004

  Yes

  No

  N/A

• “This disclosure does not contain information, if any exists, that is

  Yes

  No

  N/A

• protected by special state and/or federal confidentiality requirements

  Yes

  No

  N/A

• If you believe that the information you wish to withhold is covered by such a special a specific authorization for disclosure of the otherwise confidential information

  Yes

  No

  N/A

• Please note also that the law allows physicians to share medical information for both the law requires physicians to share medical information under some circumstances

• (e.g., pursuant to a valid court order)

  Yes

  No

  N/A

Sample Office Procedures

• Page 79 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

SAMPLE AUTHORIZATION TO TRANSFER MEDICAL RECORDS

• I hereby authorize , M.D., to furnish medical information concerning (patient’s name) to Dr

  Yes

  No

  N/A

• (physician’s name and address)

• Any and all information may be released, including, but not limited to, mental health records and/or HIV rest results, if any, except as specifically provided below:

  Yes

  No

  N/A

• [Optional: I understand and agree to pay a reasonable charge to cover the cost of the

  Yes

  No

  N/A

• transfer. I understand the costs will be computed based on a copying fee of $.25

  Yes

  No

  N/A

• cents per page for standard documents, actual costs for the reproduction of oversized

  Yes

  No

  N/A

• documents or documents requiring special processing, and reasonable clerical costs

  Yes

  No

  N/A

• for locating and making the records available.]

  Yes

  No

  N/A

• This authorization is effective now and will remain in effect until

  Yes

  No

  N/A

• (date)

  Yes

  No

  N/A

• I understand that I may receive a copy of this authorization

  Yes

  No

  N/A

• Signed: Date:

  Date

• If not signed by the patient, please indicate relationship:

  Yes

  No

  N/A

• [] parent or guardian of minor patient

  Yes

  No

  N/A

• [] guardian or conservator of an incompetent patient

  Yes

  No

  N/A

• [] beneficiary or personal representative of deceased patient*

  Yes

  No

  N/A

• Note: To be valid, this authorization must be handwritten by the person who signature which serves no purpose other than to execute the authorization

• * It is unclear whether the beneficiary or personal representative of a deceased

  Yes

  No

  N/A

• patient can obtain and disclose certain specific records, such as the patient’s mental

  Yes

  No

  N/A

• health records, and/or HIV test results

  Yes

  No

  N/A

Sample Office Procedures

• Page 80 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

SAMPLE AUTHORIZATION FOR RELEASE OF MEDICAL

INFORMATION

• I hereby authorize , M.D., to furnish medical to

  Yes

  No

  N/A

• (name and address of person to receive records)

  Yes

  No

  N/A

• Any and all information may be released, including, but not limited to, mental health records and/or HIV test results, if any, except as specifically provided below:

  Yes

  No

  N/A

The information may be used only for the following purposes:*

• This authorization is effective now and will remain in effect until

  Yes

  No

  N/A

• (date)

  Yes

  No

  N/A

• I understand that I have the right to receive a copy of this authorization

  Yes

  No

  N/A

• Signed: Date:

  Date

• If not signed by the patient, please indicate relationship:

  Yes

  No

  N/A

• [ ] parent or guardian of minor patient (to the extent minor could not have consented to the care)

  Yes

  No

  N/A

• [ ] guardian or conservator of an incompetent patient

  Yes

  No

  N/A

• [ ] beneficiary or personal representative of deceased patient **

  Yes

  No

  N/A

• [ ] spouse or person financially responsible (where information solely for purpose of processing application for dependent health care coverage)

  Yes

  No

  N/A

• * Signed: Dated:

  Yes

  No

  N/A

• Physician

  Yes

  No

  N/A

Sample Office Procedures

• Page 81 of 98

  Yes

  No

  N/A

• January 2004

  Yes

  No

  N/A

• For the release of records (1) protected by the Lanterman-Petris-Short Act (LPS) or

  Yes

  No

  N/A

• (2) containing HIV test results, a separate authorization is required for each separate

  Yes

  No

  N/A

• disclosure. Further, the LPS Act often requires that both the patient’s treating

  Yes

  No

  N/A

• physician and the patient, or representative, sign the authorization form before

  Yes

  No

  N/A

• information may be released

  Yes

  No

  N/A

• ** It is unclear whether the beneficiary or personal representative of a deceased

  Yes

  No

  N/A

• patient can obtain and disclose certain specific records, such as mental health records

  Yes

  No

  N/A

• covered by the Lanterman-Petris-Short Act (see this Chapter, section entitled “The question #12) and/or HIV test results (see this Chapter, section entitled “Special