Accounting of Disclosures

Category: Privacy

Date: March 2003

Reviewed/Revised: April 2013

I. General Policy on Accounting for Disclosures

Each clinical department or division is required to document in the patient’s medical record or EHR each non-routine disclosure made, unless exempt by law or already documented by an authorization.

This list of disclosures must include the following information:

• Date of the disclosure
• Description of the information which is disclosed
• Reasons for the disclosure
• Person(s) or places receiving the protected health information

Patients have a right to an accounting of disclosures made of their protected health information (PHI) within the 6 years prior to their request. All patient requests must be submitted in writing and forwarded to the Privacy Office.

II. Requirement to Track Disclosures

A. Disclosures subject to tracking

1. Each clinical department or division must track the following disclosures:
   • Uses and disclosures required by law
   • Uses and disclosures for public health activities
   • Disclosures about victims of abuse, neglect, or domestic violence
   • Uses and disclosures for health oversight activities
   • Disclosures for judicial and administrative proceedings
   • Disclosures for law enforcement purposes
   • Uses and disclosures about decedents
   • Uses and disclosures for cadaveric organ, eye, or tissue donation purposes
   • Uses and disclosures for research purposes where there is not a patient authorization (IRB issued waiver)
   • Uses and disclosures to avert a serious threat to health or safety
   • Uses and disclosures for specialized government functions
   • Disclosures for workers’ compensation
2. All disclosures subject to tracking will be entered into the Disclosure Log located in the patient's medical record or EHR. Disclosures may be recorded in the EHR using the following process.
   • Access the patient’s EHR.
   • Click on “Note”; “New Note”; “Unstructured”; “Note Type”.
   • Choose “Disclosure”.
   • Click on “Text” located at the bottom of the page.
   • Click on “Disclosure Log” indicated in the red brackets.
   • Click inside the brackets for “Requestor Name” and “Company” and enter the appropriate information.
   • Under “Reason for Disclosure”, double click on the reason for the disclosure.
   • Click on “Sign” and enter your password.
   • The document will appear in grey with the signature noted indicating finalization.

B. Exceptions to disclosure accounting

A department or division is not required to account for these disclosures:

• Any disclosure made more than six years prior to the request
• Disclosures to the individual or the individual’s personal representative
• For treatment, payment, or health care operations
• Disclosures made under a valid authorization
• Disclosures made for notification of persons involved in an individual’s care
• For national security or intelligence purposes
• To correctional institutions or law enforcement officials regarding inmates

A temporary suspension of the right to accounting of disclosures is allowed for health oversight agencies or law enforcement officials contingent on the submission to the department or division of a statement that indicates that an accounting of disclosure will impede an investigation that involves the individual in question. The statement should include a time frame for the exclusion period. The statement may be oral but in that case the temporary suspension is limited to 30 days unless appropriate written documentation is submitted within 30 days. Although the accounting of disclosure information is not being released during this period, the department or division should continue tracking and storing the information for future release.

III. Request for disclosure list

An individual must submit a written request for a disclosure list to the department or division for processing. The request must include the following information:

• Patient name
• Date of birth or social security number
• Date range requested
• Signature
• Date of request

If the individual prefers, the EVMS Medical Group Accounting of Disclosures of Health Information Request Form may be completed.

IV. Response to Accounting Requests

1. The department or division must provide an accounting of disclosures within 60 days of the request. If the department or division cannot honor the request within the 60-day period, it must provide information to the requestor as to the reason for the delay and expected completion date. Only one extension is permitted per request. 
2. The department or division will notify the individual of any charges associated with the accounting to ensure that the individual still wants the accounting.
3. The department or division will gather and prepare the disclosure accounting to include the Disclosure Log as well as disclosures made by business associates. In addition, the department or division will determine if any disclosure to health care oversight or law enforcement officials is subject to temporary suspension. The Disclosure Log in the EHR may be printed by returning to “Chart” and “Chart Viewer” to locate the “Disclosure Log”. All accounting of disclosure requests should be reviewed by the Privacy Office prior to notification of the individual.
4. The department or division will notify the individual when the accounting is ready, requesting payment if charges are due, but otherwise transmitting the disclosure accounting to the individual.
5. Cost. An individual is allowed to request free of charge one accounting within a 12-month period. A twenty-five dollar fee per patient request may be charged, payable in advance by the patient. The accounting of disclosure list will include all disclosures of PHI subject to tracking for all clinical departments at EVMS Medical Group.