[MT-L] Sealing a record in EMR vs Confidntial patients

[Hite, Betty]

Hi all,

In the past year, we've had requests to protect patient information both
during an inpatient stay and for some outpatient records. Depending on
the situation, we used the Seal EMR record and of course at times
Confidential patient flag.

Does anyone have experiences or thoughts regarding the two functions
they would be willing to share with us?

Could you consider the following questions?

* Who is permitted to request a visit/record be sealed?

* What criteria do you use for making a record confidential vs.
sealing it?

* How do you determine whether to seal the current visit vs. the
entire record?

* Do you ever unseal a visit/record?

* What process do you have for ensuring all users needing it are
given access via the MRI Seal Patient EMR Routine?

* Have you encountered any problems with the Seal Patient EMR
routine which we should be aware?

Thanks in advance for your responses.

Betty Hite, RN

Clinical Applications Coordinator, IS

Augusta Health

78 Medical Center Drive

Fishersville, VA 22939

[Laura Wilson]

We regularly seal records in the EMR for a variety of reasons. When are record is sealed, the director of medical records, and an information systems staff member are given access to the sealed record. We do unseal records but not often. I have not personally encountered any issues with sealing/unsealing records.

On occasion, we flag an acute patient as confidential per the patients request, but all our Behavioral Health patients are all set as confidential. For us this mostly serves as a "flagging" method. Because clinical personnel need to access these confidential patients, there are relatively few (clinical) staff who don't have access to confidential patients.

WARNING: An issue with sealing the patient in the EMR is that it can leave you with a false sense of security. Yes, the record is sealed in the EMR, however, there is no way to see this patient in the various modules. We have had instances of litigation in which no one needs to access/view/print the record, but there is no way to secure it outside the EMR.

I would love to hear of a site who has managed to circumvent this issue. I have had lengthy discussions with Meditech regarding this. Essentially they concur that it is a problem, but have no solution.

Laura Wilson Asst Dir, I.S.

INFORMATION SYSTEMS
770.836.9791  | www.tanner.org

Hi all,

Betty Hite, RN

Clinical Applications Coordinator, IS

Augusta Health

78 Medical Center Drive

Fishersville, VA 22939

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