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Policy No.: '''6045'''<br />
 
Policy No.: '''6045'''<br />
 
Effective Date: '''11/21/03'''<br />
 
Effective Date: '''11/21/03'''<br />
Revised Date: '''08/28/18'''<br />
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Revised Date: '''07/01/19'''<br />
Reviewed Date: '''08/28/18'''<br />
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Reviewed Date: '''06/17/19'''<br />
 
<br />
 
<br />
 
<big>'''Privacy, Confidentiality and Security of Patient and Proprietary Information Policy'''</big><br /><br />
 
<big>'''Privacy, Confidentiality and Security of Patient and Proprietary Information Policy'''</big><br /><br />
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:*is created or received by ACE; and
 
:*is created or received by ACE; and
 
:*relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.
 
:*relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.
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*'''Workforce''' means employees, the medical staff, volunteers, trainees, and other persons whose conduct, in the performance of work for UNMC is under the direct control of UNMC, whether or not they are paid by UNMC.
 
==Other Definitions==
 
==Other Definitions==
 
*'''Controlled Unclassified Information (CUI)''' as defined by U.S. Presidential Executive Order 13556 is information that requires safeguarding or dissemination controls pursuant to and consistent with applicable law, regulations and government-wide policies but is not classified under Executive Order 13526 or the Atomic Energy Act, as amended.
 
*'''Controlled Unclassified Information (CUI)''' as defined by U.S. Presidential Executive Order 13556 is information that requires safeguarding or dissemination controls pursuant to and consistent with applicable law, regulations and government-wide policies but is not classified under Executive Order 13526 or the Atomic Energy Act, as amended.
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*'''Proprietary Information''' is information relating to business practices, including but not limited to financial statements, contracts, and business plans; employee records; student records; and meeting minutes.
 
*'''Proprietary Information''' is information relating to business practices, including but not limited to financial statements, contracts, and business plans; employee records; student records; and meeting minutes.
 
*'''Student Education Records''' means any information recorded in any way which directly relates to a student and is maintained by or on behalf of UNMC (education agency/institution). Student education record does not include a (i) sole possession record, (ii) law enforcement record, (iii) employee record of a person who is employed by UNMC by virtue of his or her status as a student at UNMC (e.g. work study, assistantships, resident assistants), (iv) alumni record and (v) medical record that is part of the common medical record shared by the Affiliated Covered Entity. Student education records are covered by the Family Educational Rights and Privacy Act (FERPA).
 
*'''Student Education Records''' means any information recorded in any way which directly relates to a student and is maintained by or on behalf of UNMC (education agency/institution). Student education record does not include a (i) sole possession record, (ii) law enforcement record, (iii) employee record of a person who is employed by UNMC by virtue of his or her status as a student at UNMC (e.g. work study, assistantships, resident assistants), (iv) alumni record and (v) medical record that is part of the common medical record shared by the Affiliated Covered Entity. Student education records are covered by the Family Educational Rights and Privacy Act (FERPA).
*'''Workforce''' means employees, the medical staff, volunteers, trainees, and other persons whose conduct, in the performance of work for UNMC is under the direct control of UNMC, whether or not they are paid by UNMC.
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==Procedures==
 
==Procedures==
 
===Patient Information===
 
===Patient Information===
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*The ACE is responsible for safeguarding and protecting PHI against loss, tampering, and disclosure to unauthorized individuals. The safeguarding of PHI in any form includes when the information is stored and/or being transferred outside the facility (see UNMC Policy No. 6073, [[Transporting Protected Health Information]]).
 
*The ACE is responsible for safeguarding and protecting PHI against loss, tampering, and disclosure to unauthorized individuals. The safeguarding of PHI in any form includes when the information is stored and/or being transferred outside the facility (see UNMC Policy No. 6073, [[Transporting Protected Health Information]]).
 
*ACE workforce have a duty to protect PHI. Breach of this duty includes the following:
 
*ACE workforce have a duty to protect PHI. Breach of this duty includes the following:
:*Accessing PHI, in any form, without a "need to know" to perform assigned duties. Workforce members with medical information system access may view their own individual medical records. Workforce members may not print copies of their own records nor access records of family members (including children), relatives, friends and others, unless access is necessary to perform assigned duties. Workforce members may obtain a copy of their medical records from the Health Information Management Department. Workforce may not alter their own medical record.
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:*Accessing PHI, in any form, without a "need to know" to perform assigned duties. Workforce members may not access their own records. Workforce members may not access records of family members (including children), relatives, friends and others, unless access is necessary to perform assigned duties. Workforce members may obtain a copy of their medical records from the Health Information Management Department via the online patient portal.  
 
:*Discussing or disclosing patient care events to individuals who do not have a “need to know” to perform assigned duties, even if the patient’s name is not mentioned. The facts surrounding patient care are confidential and can lead to the identity of the patient.
 
:*Discussing or disclosing patient care events to individuals who do not have a “need to know” to perform assigned duties, even if the patient’s name is not mentioned. The facts surrounding patient care are confidential and can lead to the identity of the patient.
 
:*Disclosing PHI without proper authorization (see UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]]);
 
:*Disclosing PHI without proper authorization (see UNMC Policy No. 6057, [[Use and Disclosure of Protected Health Information]]);

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