PDA

View Full Version : Is sharing nursing notes and hospital notes with physician a HIPPA violation


merapple
Jul 16, 2010, 10:01 PM
Pediatric patient has homehealth. Patient has lived with grandparents for 4 years. Mother has now come back into picture. For the best interest of the child, is it a HIPPA violation for a nurse to dicuss homehealth record with physician during hospitalizations.

tickle
Jul 17, 2010, 03:50 AM
They are supposed to do that merapple, it is called discussing the care plan for a patient. Without that communication between a nurse and doctor the health of a patient would not be resolved. Doctors have to be updated, along with notes, and the nursing sector input.

Tick

ScottGem
Jul 17, 2010, 03:59 AM
I had to read this a couple of times because I don't understand why this question was asked. A HIPAA violation occurs when a caregiver provides information about diagnosis or treatment to a 3rd party without the patient's permission.

If the physician is also a caregiver for the patient, then how could this be a HIPAA violation? It is SOP for caregivers to share info about a patient.

J_9
Jul 17, 2010, 04:47 AM
If the physician is also a caregiver for the patient, then how could this be a HIPAA violation? It is SOP for caregivers to share info about a patient.

I'll give you an example Scott. Jane Doe comes into my hospital thinking that she is in labor. However, my hospital is not her hospital of delivery and her OB/GYN does not have privileges at my hospital. I cannot discuss her visit or treatment at my facility with her doctor of choice.

Therefore, I cannot discuss her visit or treatment with her doctor.

J_9
Jul 17, 2010, 04:49 AM
Pediatric patient has homehealth. Patient has lived with grandparents for 4 years. Mother has now come back into picture. For the best interest of the child, is it a HIPPA violation for a nurse to dicuss homehealth record with physician during hospitalizations.

Now, the question is... who are the legal guardians of the child? Is the physician of record at the hospital the same physician that has control over medical treatment at home?

The best answer in this scenario is for the two doctors to discuss this together.

merapple
Jul 17, 2010, 07:39 PM
The mother of the patient was charged with child endangerment and the grandparetns stepped in. I don't know if there is a court order for custody. I have been caring for this patient for a year and the mother came in the picture only 3 months ago...

Now we can't decide whom to send patient home with. Because we don't know who is the legal guardian anymore... My assessment is to send him home with grandparetns for safety. My notes provide evidence of mother's noncompliance in child's care last few months...

The patient has several physicians but yes this physician at this particular hospital is his PCP. The PCP is asking me for the past 3 months for nursing notes and progress notes on the patient...

Is handing the PCP my nursing notes and progress notes a hippa violation? If so, can I write a summary of events in the past few months or is this a violation as well?

ScottGem
Jul 18, 2010, 05:35 AM
Ok, if you want to protect yourself, then you need to see the court orders. If the patient is not in the home currently (you said send home with), then you need to ask for a copy of the guardianship/custodial order and check with the court to see if its still place.

From there, you need written notice from the guardian that the physician who is asking for the notes is now the PCP. With that documentation in hand, you protect yourself against a HIPAA violation (btw its HIPAA, not HIPPA).

J_9
Jul 18, 2010, 06:03 AM
I have to agree with Scott here. You need a written medical release to release the info to the doctor in question.