HIPAA

Mandatory Reporting and Accounting of Disclosures

  • 1.  Mandatory Reporting and Accounting of Disclosures

    Posted 10-19-2020 11:55 AM
    Good morning:

    A question came my way about mandatory reporting. When a provider submits a report to social services for suspected abuse or neglect, do you put a copy of the report or a note in the patient's chart? I came across a thread where the conclusion seemed to be that the report is kept out of the chart and maintained with, e.g., the compliance office.  But then how do you address the disclosure log?  I presume this would be a "disclosure" that would have to be included in an accounting of disclosures?

    Thank you!

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    Sophie Morgan
    Legal/Compliance Officer
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    19th Annual CEI Virtual Conference


  • 2.  RE: Mandatory Reporting and Accounting of Disclosures

    Posted 10-19-2020 12:26 PM
    Hello Sophie,

    I appreciate your question as I have wondered the same.  I want to know industry standard, not what we do.  I work for a BH department and I supervise the abuse investigators for BH.  We do not put the information in the client's chart because the report is confidential and we don't consider the report as part of their designated record set.  We do have a separate area in the EMR for quality and compliance.  We do account for these disclosures.

    Are you looking to adjust your process or are you asking to determine a new process.  Just curious. Thanks!  ​

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    Melanie Schoonover, MS, CRC, CHC, CHPC
    Quality Assurance Supervisor | HIPAA Privacy Manager
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    19th Annual CEI Virtual Conference


  • 3.  RE: Mandatory Reporting and Accounting of Disclosures

    Posted 10-20-2020 09:11 AM
    We do not include those in our designated record set.  We enter those into our disclosure tracking software.  It's a separate application called 3M Chart Release.   ​

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    Tara Yeaton, RHIT, CHPC
    Director of HIM Operations
    Deputy Privacy Officer
    MaineGeneral Medical Center
    Augusta, Me
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    19th Annual CEI Virtual Conference


  • 4.  RE: Mandatory Reporting and Accounting of Disclosures

    Posted 10-20-2020 09:40 AM

    Hi, Melanie:  

    We currently keep these in an Administrative/Legal part of the chart - not within the designated record set.  It sounds like we use a similar practice that you use.  I was wondering what others did, and how they log the disclosures when they keep the reports in a separate system or office and whether it would be worth migrating to a different process.

    Thanks! 



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    Sophie Morgan
    Legal/Compliance Officer
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    19th Annual CEI Virtual Conference


  • 5.  RE: Mandatory Reporting and Accounting of Disclosures

    Posted 10-20-2020 07:29 AM
    I believe the criteria for inclusion in the Designated Record Set is any information used to make health care decisions for the patient. I do not think an AOD would be included in that criteria. Thus, a general AOD log would be a preferable option.​

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    Dr. Randy Lewis, LMFT, CHPC
    HIPAA Privacy Officer
    Orange County Government
    Orlando, FL
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    19th Annual CEI Virtual Conference


  • 6.  RE: Mandatory Reporting and Accounting of Disclosures

    Posted 10-20-2020 09:19 AM
    The report itself never goes in the record  to protect the reporter and the findings do not go into the record or in a progress note unless it is indicated.  If it is entered into the record and is unfounded, the record would need to be redacted.  It basically work on the premise that an individual is innocent until proven guilty.  And, even after a positive finding, the individual may appeal and win which would again lead to redacting the record.

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    Lisa Hanson
    Director of Q.A. and Compliance
    Mental Health Association in Ulster County, Inc.
    Lake Katrine,NY
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    19th Annual CEI Virtual Conference