Health Information Management

HIPAA Q&A: You've got questions. We've got answers!

HIM-HIPAA Insider, May 4, 2015

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Submit your HIPAA questions to Editor Jaclyn Fitzgerald at and we will work with our experts to provide you with the information you need.

Q: Do we need to cross out patients' names after they sign in for an appointment? My facility does not do this, as it is only their name and other patients can see them sitting in the waiting room or walking in the hall. 
A: It's a good idea to cross out patient names on sign-in sheets several times during the day. OCR issued guidance—last updated March 14, 2006—noting that it is permissible to use sign-in sheets if the CE has implemented reasonable safeguards and the minimum necessary standard is addressed, where appropriate. For example, the sign-in sheet may not display medical information that is not necessary for the purpose of signing in (e.g., the medical problem for which the patient is seeing the physician). Just including the patients' names is usually considered incidental disclosure of PHI.
You should ensure even patient names are not left visible on a sign-in sheet if the treatment is in a setting where just knowing the patient is being seen can disclose the diagnosis. For example, if the treatment provided is related to mental health or alcohol and chemical dependency, consider it sensitive and regularly block out patient names. On the other hand, if the sign-in sheet was used at a primary care clinic, knowing who signed in for an appointment is not likely to disclose a medical condition. Patients may be able to see each other in a waiting area, but that doesn't mean the patients know each other's names.
Editor’s note: Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, Oregon, answered this question for HCPro’s Briefings on HIPAA newsletter. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions.


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