Hospice Care of Southwest Michigan Hospice
Policies and Procedures Volume I, Chapter 1 Rights/Responsibilities/Ethics

Chapter Leader:  Director of Counseling Services

Chapter 1:  Rights, Responsibilities and Ethics


COP: 418.74    Effective: 06/21/96 1 Revision: 08/09/16

 Hospice Care of Southwest Michigan identifies as sensitive and confidential and maintains as confidential all clinical records and information related to clients.  All Hospice staff understand and agree to comply with rules and regulations governing the disclosure of client information.  No information will be released without prior written consent by the client or his/her representative.  (See Policy 1.7, Authorization for Release of Information/Authorized Representatives.)
1. Only Hospice staff involved in the care or supervision of care of specific clients will have access to clients’ clinical records.
2. Clients will not be discussed by clinical or non-clinical staff outside of the context of professional conversation regarding client's condition and care.  Conversations regarding any client are not to be conducted in a public area.
3. Clinical records will not be released to any third party without a written authorization from the client or his/her representative.
4. The client/Authorized Representative will sign an Authorization for Release of Information/Authorized Representatives Form 209 at the information or admission visit.  This form indicates all known persons, and agencies with which contact may be made. 
5. When the client/caregiver or Hospice identifies another agency or person with whom information may be exchanged regarding the client, a second Authorization for Release of Information/Authorized Representatives Form will be completed and signed.  This form is an addendum to the form signed at the time of the information or admission visit.
6. Hospice personnel will only provide client information to those persons authorized by client or client representative.  For purposes of identification, the following information is recommended:  name, relationship, address, and phone number for each person authorized to receive information regarding client.
7. All requests for client information will be reviewed by the appropriate Hospice personnel to determine whether this information can be made accessible.  Requests for information that may not be released will be referred to the Chief Executive Officer.
8. Copies of clinical records or excerpts of it cannot be removed from Hospice except by subpoena, where statutory law requires it, or on written authorization of Hospice.  This confidential information is treated as such and is to be mailed in an envelope designated “confidential.”
9. Clients will be allowed access to their clinical records during regular office hours after giving reasonable notice to the Chief Executive Officer or designee.   

 10. Clinical records will be maintained as confidential per the safeguarding/retention of clinical record policy (See Policy 10.5).  Specific measures include keeping confidential information filed when not in use, removing documents from faxes/printers as soon as possible, and obscuring confidential information in “line of sight” on desks and computer monitors.
11. Client information contained in the computer data program is treated as confidential.  Access to this system requires a name and designated password to maintain confidentiality.  Staff will only access information on the computer via their individual password.
12. Information contained in performance improvement reports will not contain individual client or staff information.
13. Personnel are strictly prohibited from using their agency cell phone’s camera function.  Staff are further prohibited from using any personal cell phone’s camera function during the course of work.
14. All Hospice staff will be required to sign a confidentiality statement during their orientation process.  (Confidentiality Statement, Form 5A.)
15. Any breach in confidentiality on the part of Hospice staff is grounds for possible termination.