Health Information Management

HIPAA: Transcription, breaches, and PHI for research

HIM Briefings, November 1, 2008

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Q. May a transcriptionist type a medical report pertaining to a visit between the physician and a member of the transcriptionist’s family?

A. HIPAA states that covered entities (CE) must take reasonable steps to mitigate against incidental disclosures. Specifically, an organization must take all reasonable precautions to ensure that access to protected health information without patient authorization is limited to only those individuals who need to know. CEs must restrict the information to that which is minimally necessary to accomplish the purpose of the disclosure. Most facilities have implemented policies that require staff members to notify a supervisor when a family member’s record is presented to them.

In this situation, the transcriptionist typically must find someone else to transcribe the report, when possible. However, in a small facility or emergent situation in which no alternative exists, transcriptionists should be able to override this policy.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to HIM Briefings.

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