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Serving Patients by Facilitating the Education of Future

Health Care Professionals

Welcome! We’re delighted that you’re advancing your education at Lakeview Medical Center. This packet covers information on confidentiality, HIPAA, harassment, professional attire, emergency procedures, and safety.

Questions: Contact Volunteer Services 715-236-6255 CONFIDENTIALITY

Confidentiality is our conscious effort to keep patient information private, including:

Patient physical and mental health: diagnosis, treatments, test results, medical history Personal information: work or family Admission data: date, time, provider, reason Financial/insurance: source of payment, account balance Patient information may be in the form of: Charts and files Computerized information

Information you, another co-worker or a patient sees or overhears

You must not use the hospital’s patient records, computerized information and/or financial records to retrieve information about yourself, your spouse, dependents, family members or friends.

Patient information may be disclosed on a “need-to-know” basis without written authorization to people responsible for: Treatment Payment

Other health care purposes

Disclosure of patient information for all other purposes requires written authorization. This includes release of information to a patient’s immediate family. Such information requests must be directed to Medical Records Department. Information concerning the hospital must also be kept private, including: Financial Status Business practices

Strategic plans Marketing plans

HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT Patient expectations about privacy and confidentiality are important to providing quality health care. Lakeview Medical Center is committed to protecting the privacy of their patients and members.

The Health Insurance Portability and Accountability Act of 1996 and its implementing regulations (“HIPPA privacy requirements” or “HIPPA”) create a new uniform minimum standard for the use and disclosure of protected health information. We had to comply with HIPAA privacy requirements by April 14, 2003. No matter where you work (patient care areas, lab, administration, pharmacy, business office, medical records, information systems) and what your position (physician or employee), it is your obligation to protect patient privacy by handling and maintain protected health information in a confidential manner.

Confidentiality can be defined as a conscious effort to keep patient information private.  True or False

When outside the hospital and referring to your learning experience, you cannot mention patient names or patient information you encountered.  

True or False 

The mission of Lakeview Medical Center is to enhance the health of the communities we serve. 

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Protected Health Information – What is it? “Protected health information” (PHI) can be information related to: The past, present or future physical or mental health or condition of a person The process of providing health care to a person The past, present or future payment of health care services provided to a person

Not all health information is PHI because it must also be “individually identifiable.” Generally, this means that someone seeing or hearing the health information can identify the person it is about or could easily link heath information to a specific person. The following identifiers make health information individually identifiable:

Name Address Telephone or fax number Birth date E-mail address Social security number Driver’s license number Medical or health record number Account number Health insurance plan identification

number

Full-face photographic images Certificate or license number Vehicle or other device serial

number Biometric identifiers (such as finger

or voice prints) Internet Protocol (IP) address or

Web Universal Resource Locators (URLs)

Protected Health Information – Where is it located? PHI is more than just a patient’s medical record. PHI can be written, oral, electronic, digital or

recorded. The following are some examples of PHI: A postcard with an appointment or treatment reminder for a patient Billing/payment information An appointment reminder message (with clues about the patient’s medical condition or type of

specialist the patient is seeing) left on an answering machine A telephone call to verify health insurance coverage A Word document, Excel spreadsheet or Access database containing PHI E-mail containing PHI PHI stored in palm pilots and other handheld devices, laptops, discs, CDs, electronic memory chips

or magnetic tapes Faxes containing PHI Prescription bottles with labels

Minimum Necessary Standard and Safeguards The minimum necessary standard is a key protection of HIPAA. It is based on the principle that PHI should not be used or disclosed if that use or disclosure is not necessary or appropriate. This means we must generally limit uses or disclosures of PHI to the minimum necessary to accomplish the intended purpose. This is similar to the “need to know” rule that we are all familiar with – if you need to see or obtain patient information to perform your job, you are allowed to do so but only what you need to do your job. You don’t need to worry about this rule if you are disclosing PHI to a health care provider for treatment purposes or you are a health care provider who is requesting PHI for treatment purposes.

Two employees are sitting in the cafeteria. One employee says to the other: “I can’t get the gastric bypass surgery pre‐authorized for the patient in room 8 over at St. Luke’s hospital.” Did the employee disclose PHI? 

a. No, a casual conversation is not PHI b. Yes, someone could identify the patient from what the employee said c. No, the patient’s medical history number was not used.  d. No, the patient’s name was not used.  

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Certain incidental uses and disclosures of PHI are allowed as long as we have applied reasonable safeguards and implemented the minimum necessary standard. We cannot guarantee the privacy of PHI from any and all potential risks but must take reasonable steps to safeguard it from unauthorized uses and disclosures. An incidental use or disclosure is a secondary use or disclosure that cannot reasonably be prevented, is limited in nature, and that occurs as result of another use or disclosure that is permitted by HIPAA. The following steps can be taken to safeguard PHI from unauthorized uses or disclosures:

Avoid using patient names or other information that can easily link health information to a specific person.

If it’s not possible to move to a private room, lower your voice. Move to a private or semi-private room.

HIPPA doesn’t specifically address what information to leave in messages on answering machines, but the minimum necessary standard requires that we disclose only the minimum information necessary to get the job done. Otherwise, family members or others may overhear PHI in the message – PHI that the patient may not wish them to know about.

Patients trust you to keep their health information confidential. Don’t share PHI with anyone who is not authorized to know it. As tempting as it may be to share PHI with your spouse or friends, you must remember that you have an obligation to keep PHI confidential on and off the job.

Patient Privacy Rights HIPAA gives patients new rights including: The right to be informed of the privacy practices of their health care providers and health plans, as

well as their privacy rights regarding their PHI The right to request restriction of uses or disclosures of their PHI for treatment, payment or health

care operations The right to request to receive communications of PHI by alternative means or at alternate locations The right to access (inspect and copy) their PHI The right to request amendment of their PHI The right to receive an accounting of disclosures of PHI made for certain purposes without written

authorization If patients ask you about these new privacy rights, you should refer them to Medical Records.

Sanctions for Privacy Violations When you follow our privacy and confidentiality policies, you not only help protect our patients’ privacy but also our organization and yourself from sanctions. Failure to follow these policies may result in disciplinary action, up to and including termination and lead to civil and criminal liability.

Sanctions under HIPAA can include monetary fines and jail time: $100 for each violation of the law, up to $25,000 per year for violations of the same requirement.

Multiple violations of different requirements can result in additional fines. Up to $50,000 and 1-year jail sentence for knowingly using or disclosing PHI in violation of HIPAA. Up to $100,000 and 5 years in jail for gaining access to PHI under false pretenses. Up to $250,000 and 10 years in jail for using or disclosing PHI with harmful intent or for sale or other

personal or commercial gain. In addition to sanctions under HIPAA, there are sanctions under Wisconsin law that can include monetary fines, forfeitures and jail time.

Because you are a health care professional or work in a health care facility, you have an obligation to keep PHI confidential: a. 24 hours a day, 7 days a week b. During work hours only c. During weekends d. Whenever you feel like it

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HARASSMENT Workplace Harassment Definition A form of unlawful discrimination that includes all types of physical or verbal conduct showing hostility toward a person because of a person’s sex, race, religion, national origin, disability or any other legally protected status listed below: Race Disability Creed Sexual orientation Handicap Veteran’s status

Medical Condition Color Age Ancestry Use of lawful products Conviction record

Religion Marital status National origin Sex (gender) Arrest Record National Guard

Legally protected statuses are protected by Title VII of the Civil Rights act of 1964, the Age Discrimination in Employment Act, the Americans with Disabilities Act, and state discrimination laws.

Harassment is prohibited whether it occurs in person, in writing, by telephone, fax, email, via the Internet or any other communication. Examples of Prohibited Harassment: Ridiculed for wearing the traditional Indian sari dress to work Manager informs a subordinate she will promote him if he sleeps with her Group of employees subject a co-worker to a barrage of comments about his strict religious beliefs,

conservative lifestyle and involvement in church activities Manager excludes an employee from an IS training course stating it would be a waste of time

because ‘you can’t teach an old dog new tricks’

Sexual Harassment Definition Sexual harassment generally involves unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature when: Submission to such conduct is made an implicit or explicit condition of employment Submission to rejection of such conduct affects employment opportunities

OR the conduct interferes with an employee’s work or creates an intimidating, hostile or offensive work environment. Sexual harassment may occur in two forms: Hostile environment” and “quid pro quo”. Quid Pro Quo (Tangible Harassment) occurs when someone in the position of authority promises or threatens an employment action, decision or expectation based on an employee’s willingness to grant or deny sexual favors. The harasser may be male or female. Examples: Demanding sexual favors in exchange for a promotion/raise. Disciplining or firing a subordinate who ends a romantic relationship Changing performance expectations after a subordinate refuses repeated requests for a date.

Hostile Environment occurs when unwelcome sexual conduct unreasonably interferes with an individual’s job performance or creates an intimidating or offensive work environment. Examples:

Off-color jokes or teasing Comments about body parts or sex live Suggestive pictures, posters, calendars, screen savers

Addressing All Forms of Harassment If you’re offended, don’t hesitate to make it clear to the harasser that it must stop. If you feel you are being harassed, or you know someone who is, contact Human Resources, 715-

236-6134.

Unwelcome sexual advances would be one definition of sexual harassment?  True or False

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PROFESSIONAL ATTIRE AND APPEARANCE Proper attire and personal cleanliness are expected, since they affect staff morale and the hospitals image. Dress according to your position’s requirements and hospital policy. Failure to do so will result in your being sent home to return in proper attire. Guidelines:

Display good hygiene and neatness Keep hair away from face in patient care

areas Wear minimal jewelry Use colognes/perfumes conservatively

Wear clean shoes with socks or nylons Have nametag on at all times NOT permitted: Sandals/thongs,

sweatpants, sweatshirts, T-shirts, jeans, shorts and skorts

Some residents and students must wear surgical scrubs:

Provided scrubs remain property of the institution

Ask your mentor to learn where to obtain scrubs

Wear scrubs only within the medical complex

Do not take scrubs home Return scrubs through laundry system To prevent scrub shortages, do not

stockpile (clean or dirty)

EMERGENCY PROCEDURES Security Emergency If you notice suspicious, disruptive or threatening persons, or someone vandalizing or stealing: Dial 911 Give the operator the location and situation

Missing or Abducted Child If a child is missing or abducted: Dial 911 Give operator as much information as possible about the child Centers with overhead paging will announce description of the child Assist staff looking for the child, if you’re not with a patient Do not try to stop the abductor yourself, but report observations to the authorities

Fire Alarm Situation Use the acronym R.A.C.E. for all fire situations: Rescue/remove persons in immediate danger Alarm: dial 911 to report the location and pull the fire alarm pull station Confine the fire by closing doors and shutting off fans, med. Gases, and electrical equipment Extinguish (if safe to do so)

When using a fire extinguisher, remember the acronym P.A.S.S. Pull the pin Aim the hose at the base of the fire Squeeze the handle Sweep back and forth across the base of the fire

Evacuation Procedures The hospital is outfitted with 2-hour fire safe zones which minimize the need for a full building evacuation. Instead, in the event of an emergency situation, such as a fire, a partial/horizontal evacuation is practiced by moving to the next adjacent fire zone. These can be recognized by the presence of 2-hr fire rated doors.

Sandals, jeans and shorts are considered professional attire:  

True or False 

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Some emergency situations may warrant the need for a full evacuation. A detailed evacuation announcement will be overhead paged and will include: Areas to be evacuated Meeting location Elevators to use for non-ambulatory patients Instructions for whether staff and patients to remain on site or leave

Medical Emergency Use for anyone who needs immediate medical help:

Dial 911 Give location, nature of the emergency and age of the

patient Post someone in hallway to direct emergency personnel to

the patient IF TRAINED, start emergency care (i.e. CPR)

Sever Weather Alert In Wisconsin, we need to prepare for threatening weather emergencies such as strong winds or tornados. The local county emergency government office issues tornado watches and warnings. Tornado watch: weather conditions are favorable of producing tornados Tornado warning: a tornado has been sighted or detected by radar

If a severe weather alert is announced via overhead paging: Move patients into interior hallways away from windows if possible Cover patients with blankets and pillows, especially if they are not able to be moved Close doors to outer rooms and offices If not directly involved in patient care, seek shelter in a safe area Remain in safe areas until an all clear is announced

PATIENT AND VISITOR INCIDENTS Incidents not consistent with the hospital’s routine care must be reported to your mentor, including: Accidents that happen to you, such as a fall Expressions of dissatisfaction with service Near accidents Exposure to contagious diseases

HAND HYGIENE The single most important means of preventing the spread of infections in the hospital is hand hygiene. Proper hand hygiene is the most important action we can take to prevent the transfer of microorganisms between patients and health care workers. Wearing gloves is NOT a substitute for hand hygiene! Hands must be washed with soap and running water. To properly do this, apply soap and use friction for at least 20 seconds, then rinse and dry hands with paper towel. Then use the paper towel to shut off the faucet. This must be done anytime hands are: Contaminated with blood or body fluids After using the restroom Before and after eating After removing gloves that are contaminated with blood or body fluid

Hand sanitizers and gels containing over 60% alcohol are effective in inhibiting growth and multiplications of organisms on hands. Apply gel and rub hands together covering all surfaces of hands and fingers. Continue rubbing until completely dry.

If a child is missing and/ or abducted, try to immediately stop the abductor yourself.  

True or False

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Routine hand hygiene (either with soap and water or waterless alcohol gel) is required: Upon entering patient’s room before touching a patient Before initiating a clean/aseptic procedure After body fluid exposure risk After touching a patient After touching the patient surroundings

COVER YOUR COUGH Influenza (flu) and other serious respiratory illnesses like respiratory syncytial virus (RSV), whooping cough, and severe acute respiratory syndrome (SARS) are spread by cough, sneezing or unclean hands. To help stop the spread of germs, do not come to work when you have respiratory symptoms with fever. Cover your mouth and nose with a tissue when you cough or sneeze Put your used tissue in the waste basket If you don’t have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands You may be asked to put on a facemask to protect others Wash your hands often with soap and warm water for 20 seconds If soap and water are not available, use an alcohol-based hand rub

BLOODBORNE PATHOGENS AND EXPOSURES Pathogens are microorganisms that are present in blood or other potentially infectious material (OPIM) that can cause disease. Pathogens spread by blood and body fluids include, but are not limited to: Human immunodeficiency virus (HIV) Hepatitis B virus (HBV) Hepatitis C virus (HBC)

The following materials should be treated as potentially infectious: Blood Mixtures of body fluids Certain cell, tissue or organ cultures and mediums Body fluids visibly containing blood Amniotic fluid Synovial fluid Unfixed tissue or organs (does not include intact skin)

Bloodborne pathogens are transferred in three ways: Direct puncture of skin by object contaminated with infectious blood/body fluid Exposure of infectious blood/body fluid to non-intact skin (open wound on your skin) Contact of infectious blood/body fluid with mucous membranes such as mouth, nose, eyes or

sexual organs If you have exposure: Wash exposed areas with soap and water;

o For needle/sharp stick injuries gently squeeze area to induce bleeding o For splashes in your eyes, nose or mouth, flush the area with water or saline

Contact the exposure hot line by calling 9-3314 (24 hrs) (Tell contact nurse of your student status) Notify your mentor and school

Volunteer Services Phone: 715-236-6255

Mucous membranes are a potential route of entry into the body for Bloodborne pathogens.  

True or False 

Release and Waiver of Liability

In consideration of an educational experience in the Lakeview Medical Center, the undersigned individual:

• Hereby acknowledges that there are dangers and risks of personal injury or illness

inherent in observing the care and treatment of patients, in exposure to bodily fluids and other specimens, and otherwise.

• Hereby acknowledges that Lakeview Medical Center is not responsible for any

personal injury, illness, or other damages of any kind relating to my experience or exposure to patients, bodily fluids or other specimens.

• Hereby acknowledges that any bodily or personal injury, illness or other damages of

any kind arising out of or related to the educational experience will not be covered by workers compensation insurance or any other insurance coverage provided to Lakeview Medical Center.

• Hereby assumes full responsibility for any risk of bodily or personal injury, illness,

or other damages of any kind arising out of or related in any way to the educational experience in the Lakeview Medical Center system, including any risks caused by the negligence of Lakeview Medical Center.

• Hereby releases, waives, forever discharges and covenants to hold harmless Lakeview

Medical Center, its officers, directors, employees, insurers, and agents of and from all liability for any and all loss or damage, and any claim or demand on account of personal or bodily injury arising out of or related in any way related to the educational experience in the Lakeview Medical Center system, including any/all loss or damage, claim or demand arising out of the negligence of the Lakeview Medical Center.

The undersigned has read and understands this Release and Waiver of Liability.

Learner name (PRINT)

Learner signature Date

Parent name (PRINT)

Parent signature (required if learner under 18) Date

 

 

Policy Acknowledgement    

I hereby acknowledge that on I reviewed/received, and understand the following (initial all that apply):

Health Insurance Portability and Accountability Act (HIPAA) – I understand

HIPAA and agree to abide by Lakeview Medical Center’s HIPAA-related policies and procedures.

Harassment in the Workplace – I received and reviewed the Lakeview

Medical Center Harassment Policy, and understand that:

• I have the right to learn/visit in an environment free from harassment

• I have a responsibility not to engage in behavior that constitutes harassment

• If I am harassed, I have the right and responsibility to:

– communicate directly to the harasser that the harassment must stop

– report the harassment to the student program manager, the department manager or the director of employee relations

Policies & Procedures

• I reviewed/received Lakeview Medical Center’s Policy and Procedure packet and agree to follow all instructions I receive from Lakeview Medical personnel

• I read and understand Lakeview Medical Center’s policies and procedures on bloodborne pathogens, and basic safety

Confidentiality – I understand and agree that:

• All information relating to the past, present or future physical or mental health of an individual, or the provision of care to that individual, is and must remain confidential

• Access to, use and disclosure of such information is subject to federal and state laws and regulations, and Lakeview Medical Center policies and procedures explained to me

• I must maintain the confidentiality of all such information I receive, or to which I am exposed, and will comply with all laws and regulations governing the confidentiality of such information including without limitation as to HIV, addictive disease and mental health

• I will use such information only for the purpose of my educational experience at Lakeview Medical Center and will not use or disclose such information for any other purpose

Learner signature Date       

Health Information Report

Completed Health Information Report must be received a minimum of 4 weeks prior to your experience.

Name (first, MI, last) Date of birth

Attach documented proof of health information OR have health care provider sign below verifying information. Must provide medical

documentation of vaccination, titer OR disease history OR combination for each of the following:

Required Information 2 Immunization Dates Titer Date Result* Disease History Date

Measles (Rubeola)

Mumps

Rubella

Varicella (Chicken pox)

Required Information 1 Immunization Date

Tdap (received in May 2005 or later)

Annual influenza vaccine (Oct. 1 – March 1)

Highly Recommended 3 Immunization Dates Antibody Date Result Disease History Date

**Hepatitis B *If titer results are equivocal, re-immunization information must also be provided.

**Hepatitis B vaccination is voluntary, but highly recommended for any learner who may come in contact with patients, blood, and/or certain body fluids.

Must provide TB status either by PPD skin test OR QuantiFERON-TB Gold test OR negative chest x-ray.

Option 1

Must provide 2 PPD (TB skin test) results:

– One within the last 12 months

– One from the previous year (no more than 12 months prior to

the above result)

If you have never received this test or it has been more than 12

months since your last test, you will need to have a 2-step PPD.

PPD (TB skin test)

Date placed / / Date placed / /

Date read / / Date read / /

Result mm Result mm

Option 2

If you have received a positive PPD result, you must provide the

following:

– Positive PPD date and result including mm induration

– Copy of chest x-ray including the date of x-ray from within the last 12 months for first-time students

– Annual TB questionnaire from within the last 12 months (obtained from your health care provider)

Positive PPD (TB skin test) Chest x-ray

Date placed / / Date taken / /

Date read / / Result

Result mm Attach a copy of chest x-ray results

and TB questionnaire from within the last 12 months.

Option 3

Results of QuantiFERON-TB Gold TB test can be submitted

in place of the 2-step PPD. This test will require a blood

draw.

QuantiFERON-TB Gold TB test

Date taken / /

Result

Attach documented proof of health information OR have health care provider sign below verifying above information.

Health care provider signature Print health care provider name Health care provider address/phone

If you have any questions, call 1-715-236-6255. email: Koger.tammy@lakeviewmedical.org

Lakeview Medical Center follows CDC Immunization Guidelines of Health Care Workers

Confidentiality Statement

The undersigned understands that all medical information acquired as a result of his or her

participating in educational activities at Lakeview Medical Center (referred to in this Confidentiality

Statement as “medical information”) is confidential and that the undersigned is prohibited from

disclosing that information to any person or persons not involved in the care or treatment of the

patients or in the instruction of students at Lakeview Medical Center. The undersigned agrees to

protect the confidentiality of medical information as required by law at all times both during and

following his or her relationship with Lakeview Medical Center. The undersigned recognizes that

medical information may include more than paper or electronic medical records. Medical information

may be in written, oral, electronic, digital or recorded form and include, without limitation, the

following:

• Conversations between physicians, nurses and other health care professionals in connection

with or in the presence of a patient receiving care or between the undersigned and a patient

• Billing/payment information

• A telephone call to verify health insurance coverage

• A Word document, Excel spreadsheet or Access database containing medical information

• E-mail containing medical information

• Medical Information stored in palm pilots and other handheld devices, laptops, discs, CDs,

electronic memory chips or magnetic tapes

• Faxes containing medical Information

The undersigned understands that a breach of this confidentiality by him or her may result in an

action for damages against him or her, as well as against Lakeview Medical Center. Lakeview

Medical Center may terminate the undersigned’s relationship with Lakeview Medical Center based

upon a single breach of confidentiality by him or her.

/ / Student signature Date (month/day/year)

Student name (print)

9-60031 (10/12) © 2012 Lakeview Medical Center

    

Observational Experience Application

 

Name (print) First name Middle initial Last name

Address  

City State ZIP  

Country  

Home phone ( )  

Cell phone ( )  

Date of birth / /  

E-mail address

School name

Course name (if applicable)

Personal statement (what do you expect to gain from this experience)      

Information about requested experience Have you made contact with a person/department: Yes  No

Date(s) requesting

Physician/Medical staff/department  

Volunteer Services Contact Information

 

If you have any questions, call 715-236-6255 email: koger.tammy@lakeviewmedical.org       

 

Date of Experience Department

Physician/Staff