Physician Practice

Q&A: You’ve got questions! We’ve got answers!

Physician Practice Insider, October 4, 2016

Submit your questions to Associate Editor Nicole Votta at and we will work with our experts to provide you with the information you need.

Q: What recommendations do you have for handling medical records for staff members who are also patients at the organization where they work? Should we provide extra protection for these patients? What can we do to ensure that staff members are not accessing their coworkers' records without permission or need?

A: I am a firm believer in not adding special protection to any record, because it implies that some records are more confidential than others. In fact, all records are confidential and staff should not access any record unless it is necessary to do so to do their jobs. And, if it is necessary, they should only access the minimum necessary to do the job. HIPAA requires access monitoring, so your organization should conduct routine audits to determine whether staff are accessing records without a work-related reason. There is now software available that can conduct routine audits by staff member and department. This software can be used to reassure staff that their information is not being accessed by coworkers and to hold accountable those who are not following the policy/law. When a staff member raises a concern, an audit should be run to determine whether inappropriate access has occurred, and if it has, sanctions should be applied. Organizations should also consider having a policy that staff should not handle coworkers' (or family members') records (except in an emergency) without the permission of their supervisor.

All of these points should be reviewed at orientation and during (at minimum) annual training to ensure all staff understand that the organization takes such transgressions seriously and will take action as needed to protect the privacy of every patient's information.

Editor’s note: Chris Simons, MS, RHIA, answered this question for HIM Briefings. This information does not constitute legal advice. Email your questions to Associate Editor Nicole Votta at

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