Do you protect patient privacy during phone calls?

When callers ask whether their family member or friend is in your ED, what do you tell them? If you’re like most ED nurses, you’re confused about exactly what information you can share to avoid violations of patient privacy regulations.

"Many EDs have grappled with this issue since HIPAA [the Health Insurance Portability and Accountability Act] has gone into effect," says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA.

To improve compliance with patient privacy requirements, do the following:

• Obtain patient consent to release general information.

To comply with HIPAA, every ED patient must be given a copy of the facility’s notice of privacy practice to sign, says Sue Dill, RN, MSN, JD, vice president of legal services at Memorial Hospital of Union County in Marysville, OH.

"Interestingly enough, the federal law only requires that this document be given once, so if the patient is a frequent flyer and comes back five times after this, you do not have to re-give it," she says.

You should have the patient sign a written acknowledgment that they have received a copy of the privacy practice, adds Dill. "We put our notice in the consent form that they sign on arrival," she says.

This allows you to tell any caller who gives you a patient’s name that they are being treated in the ED, their room number, and their general condition, whether critical or stable, she notes.

If a patient has a family member in the ED assisting with their care, and that individual goes home and calls back to ask a question, you can answer it unless the patient requests otherwise, adds Dill. "We tell the patient we will give out information, and they have the right to object and list anyone who the patient does not want us to give information to," she says.

• Have a process for patients unable to sign the form.

If patients are unable to sign the form to acknowledge that they have received the privacy notice, this should be clearly documented, says Dill. "We then try and get the next of kin to sign this," she says. "We provide them with a copy, and if the patient wakes up later, we will give it to the patient."

If the patient is unable to sign because he or she is and no family members are present, use your professional judgment to decide if their visit should be made confidential, says Dill. "For example, if the patient is shot in the head in a gang-related shooting, I am going to not put his name on the directory in case the gang is looking for the patient to finish him off," she notes.

• Have a process for patients who want confidentiality.

Under HIPAA, patients have the right to choose to keep their visit confidential, says Dill. "This rarely happens, but if it does, the patient is what we call no publicity,’ meaning we don’t give out any information," she says.

At St. Mary Medical Center’s ED, patients are asked during the registration process whether they want their visit to remain confidential, says Lawrence. "If yes, an asterisk appears next to the patient’s name indicating to all personnel that the visit is confidential," he says. "Any inquiries about the patient are handled as though the patient is not in the ED."

However, if a family member or friend says that they have medical information, you can tell them the patient is not in the ED, but ask the caller if there is something the ED should know if the patient shows up, says Lawrence.

"That way significant history would be obtained without letting the caller know the patient is in the ED," he says. "Also, asking the caller for a call-back number might be useful."

If patients have indicated the desire for confidentiality, and you don’t feel comfortable telling callers they are not in the ED, you can tell the caller, "We don’t have any information on that person," suggests Lawrence.

"They then could be asked to leave their name and number so they could be contacted in case information became available,’" he says. "The patient then can be informed of the call and decide whether to continue the confidential visit or call the person back."


For more information about compliance with patient privacy regulations, contact:

  • Sue Dill, RN, MSN, JD, Vice President of Legal Services, Memorial Hospital of Union County, 500 London Ave., Marysville, OH 43040. Telephone: (937) 578-4202. E-mail:
  • Jonathan D. Lawrence, MD, JD, FACEP, Emergency Department, St. Mary Medical Center, 1050 Linden Ave., Long Beach, CA 90813. Telephone: (562) 491-9090. E-mail: