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Q&A: HIPAA and whiteboards

Patient Access Weekly Advisor, March 11, 2009

Q: May we use physicians’ names on whiteboards? Our emergency department wants to write consultant physicians’ names on the boards. Which HIPAA regulation applies?

A: HIPAA doesn’t specifically prohibit the use of whiteboards, but it requires covered entities to take reasonable steps to avoid incidental disclosures. Every organization should conduct a risk assessment to identify areas in which protected health information (PHI) may be vulnerable to incidental disclosure and take reasonable steps to avoid this.

Many organizations consider whiteboards too risky and too likely to expose PHI to the public or staff members who do not need to know. Consequently, many organizations consider it best practice to avoid the use of whiteboards.

However, writing a physician’s name on the whiteboard does not disclose PHI unless you also display patient information. Many organizations list the on-call physician or the day’s head nurse on whiteboards to notify staff members, patients, and families who is working on the unit. Unless you list the physician’s specialty after his or her name (e.g., psychiatrist, HIV specialist, or any other information that could suggest patient diagnoses), there should be no problem with this customer service–oriented procedure.

Editor’s note: Chris Simons, RHIA, director of HIMS and privacy officer at Spring Harbor Hospital in Westbrook, ME, provided these questions and answers. This Q&A originally appeared in the March issue of Medical Records Briefing. This information does not constitute legal advice. Consult your organization’s legal counsel for answers to specific privacy and security questions.

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