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White boards in the ED

Compliance Monitor, April 22, 2005

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Q: Our ER manager wants to list the name and location of emergency department (ED) patients. Does a white board in the ED violate the HIPAA privacy rule?

A: Maintaining a white board in the ED is permissible under the privacy rule. HIPAA does not prohibit covered entities (e.g., hospitals) from engaging in common and important healthcare practices, nor does it specify the measures that must be applied to protect an individual's privacy while engaging in these practices. The privacy rule does, however, stipulate that covered entities must implement reasonable safeguards to protect an individual's privacy. Additionally, covered entities must reasonably restrict how much information is used and disclosed, where appropriate, as well as who within the entity has access to protected health information (PHI). Covered entities must evaluate what measures make sense in their environments and tailor their practices and safeguards to their particular circumstances.

A white board in a hospital ED is permissible when reasonable precautions have been taken to protect an individual's privacy. Possible safeguards may include the following:

• Reasonably limiting access to this area
• Providing no additional information other than patient name and room location (no other PHI)
• Ensuring that the area is supervised
• Escorting nonemployees in this area
• Any other safeguard that reasonably limits incidental disclosures to the general public

The above examples of safeguards are not intended to be exclusive. Covered entities may engage in any practice that reasonably safeguards PHI to limit incidental uses and disclosures.

This question was answered by Norman S. Werner, CHE, corporate director, corporate compliance, Continuum Health Partners, Inc., New York, NY.

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