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Family members in the ED

Compliance Monitor, June 30, 2006

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Q: Should we prevent family members from entering the emergency department because they might overhear another patient's PHI?

A: The privacy rule requires you to take reasonable steps to limit incidental disclosures, including those in busy ED settings. However, building a new ED with all private rooms is not a reasonable step for most hospitals. Likewise, prohibiting all visitors, especially those visiting pediatric patients and those in potentially life-threatening situations, would be detrimental to patient care. HIPAA does not require EDs to take such drastic action.

Instead, reasonable steps to protect patient privacy might include the following:

• Drawing the curtain between ED bays to provide visual privacy
• Limiting the number of visitors allowed with each patient (one or two is probably reasonable, depending on the patient's condition)
• Asking visitors and staff to keep their voices low to limit the likelihood that others will overhear their conversations

Editor's note: Mary Brandt, president of Bellaire, TX-based Brandt & Associates, LLC, answered this question. This is not legal advice. Consult your attorney for legal matters.

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