Health Information Management

Q&A: HIPAA and nurse intake and output sheets

HIM-HIPAA Insider, January 4, 2011

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Q: Our nursing staff continues to tape patient intake and output sheets outside of patient rooms in our hospital. I have spoken to the director of nursing several times about this situation to no avail. Since only the back side of the form is visible and the forms don’t contain patient identification, she believes this is not a HIPAA violation. Also, the nurses put stickers with “high fall risk,” “NPO,” “NPO for surgery,” etc., on the outside of the patient doors. Are these practices acceptable?

A: Yes, these practices are acceptable. In the first case, the intake and output records are de-identified since they do not contain patient names or other identification. For a patient in a private room, an observer could certainly assume the form belongs to the patient in the room, but this information does not tell anything about the patient’s diagnosis. Stickers with basic information, such as “high fall risk,” are also appropriate since they contain the minimum amount of information needed for patient care/safety.
 
Editor’s note: Mary D. Brandt, MBA, RHIA, CHE, CHPS, vice president of HIM at Scott &
White Healthcare in Temple,TX, answered this question, which originally appeared in the January issue of Briefings on HIPAA.



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