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Q: Documenting HIV and sexually transmitted diseases

Compliance Monitor Q&A , February 1, 2008

Q: Can a physician dictate in the office note in a patient's medical record that the patient is HIV positive or for that matter has any sexually transmitted diseases? And if yes, is there any special treatment needed if records are requested for treatment?

A: It's always best to confer with your legal counsel on issues that deal with "supersensitive" health information. However, physicians should always be encouraged to document complete information relative to the patient's history and current conditions. Most states have specific codes for the handling of HIV and other sensitive health information including other sexually transmitted diseases and behavioral health conditions.

As for HIV related conditions, this information is necessary for caregivers to know in order to follow universal precautions to protect the healthcare provider from exposure in the care of the patient. There is special treatment needed if records are requested for treatment. Two key distinctions are offered that influence the propriety of disclosure: first, whether HIV infection represents a "primary cause" for the patient's current illness being treated; and second, whether others may be harmed by failure to disclose HIV status. [Vernillo, et. al, 11/07 BioMed Central Ltd]. While Vernillo's commentary relates to surrogates and critically ill patients, the guidance is beneficial in this situation. In most, if not all, treatment situations, the healthcare providers could be exposed to and harmed by this condition if it is not known to them at the time of the treatment.

In some cases, the physician is obligated to report the HIV condition. For example, in South Carolina, if the physician tested for HIV and the results were positive, he/she must report the results to the SC Department of Health and Environment Control (SC Code Ann§44-29-70). This requirement for reporting is common for many states and is usually governed by the state Department of Public Health or Department of Health and Human Services.

Most importantly, disclosure of a patient's protected health information, including sensitive health information, should not occur without obtain a patient's authorization. While emergency situations sometimes preclude one from obtaining an authorization, it is always best to have one before releasing information. Whereas HIPAA states that a covered entity may release information for purposes of treatment, payment, and operations--this statement continues to permit you to restrict release only when a valid authorization for release of information is received.

Your release of information authorization should meet the requirements of HIPAA for its content. The release can include additional clauses to ensure you are obtaining the patient's "informed" consent relative to these supersensitive conditions. I have seen release forms that have multiple clauses requiring the patient to initial or check off such as:

I authorize XYZ Health Care to release information in my record pertaining to the following conditions (Initial each category allowed):

  • HIV (AIDS) Autoimmune deficiency syndrome
  • Psychiatric, mental health, or behavior health treatment
  • Sexually transmitted diseases
  • Substance abuse/use

Finally, a good source of guidance on release of information regulations for your state may be available from your state Health Information Management Association. The state Health Information Management Associations are component associations of the American Health Information Management Association. Often these associations publish state-specific legal manuals.

Rose T. Dunn, RHIA, CPA, COO, of First Class Solutions, Inc., in Maryland Heights, MO, answered this question.