Attachment A

The Health Insurance Portability and Accountability Act (HIPAA) prohibits disclosure of individually identifiable health information.  This type of information is not limited to obvious sources such as patient medical records; it can be found in a variety of departments and types of records.

When we work with individually identifiable health information - for example in an audit of billing by UNC Healthcare or the Dental Faculty Practice, of research involving human subjects, or of health insurance enrollment, worker's compensation, criminal background checks, etc. - we should not record information in the working papers in a way that identifies any individuals.  Working papers should use anonymous labels for items selected for testing - for example, Medical Record #1, Patient A, or Employee #1 - and we should not make copies of documents that contain individually identifiable health information unless there is no other way to document information contained in the records.  If any copies are made or if a temporary record is kept that gives the identity of individuals whose records are included in the audit, these items should be destroyed by shredding before the final version of the audit report is released.  Examples of records that may contain information protected by HIPAA are:

Examples of Clinical Information
Complete Medical, Dental or Client Record
Death Medical Records
Partial Clinical Information including:
   Anesthesia Records
   Dental Records
   Diagnosis/Procedure Description/Name
   Discharge Summary
   Doctor's Statements for Court
   Flow Sheets
   Habilitation Plans
   Health Information from Other Facilities
   Immunization Records
   Laboratory Data
   Logs (Shift/Staff Notes, Insurance, Other)
   Medication Administration
   Medication Error Reports
   Nurses Notes
   Operative Reports
   Other Diagnostic Reports
   Pathology Reports
   Perioperative Reports
   Physician Orders
   Progress Notes
   Psychological Records & Testing Reports
   Psychotherapy Notes
   Radiology reports
   Referral Information
   Training Programs
   Treatment Plan
   X-ray Films
Examples of Administrative Information
Accident Reports
Application for Admission
Cancer Registry/Trauma Registry
Certificates (Birth, Death, Other)
Complaint Information
Correspondence, Memos (Internal and External)
Criminal Background Checks
Incident Reports (Clients)
Investigative Reports (Abuse, Neglect, Other)
Legal Papers (Commitment/Custody/Other)
Logs (Clients, Notes, Correspondence, Other)
Meeting Minutes/Notes
Photographs/Recording (audio/visual)
Examples of Educational Information
Education Plan
Other Patient-Identifiable Info
Examples of Financial Information
Banking/Direct Deposit
Billing/Remittance Advices
CAP/Respite/Eligibility Determinations
Claims Information (Insurance, Billing)
Patient Financial Status Information
Collections Information
Audit Information
Funding Justifications with Details (Grants, etc.)
Questionnaires, Forms, Other (i.e., Medicaid)
Examples of Employee/Staff Information
Disability Claims & Reports
Disciplinary Action
Employee Assistance Program Information
Employee Health Records
Health Plan Enrollment Information
Physician Notes (Absences from work)
Reference Letters
Voluntary Shared/Family Medical Leave
Worker's Compensation Claims & Reports
Credentialing/Licensing Files
Examples of Social Programs
Applications/Forms/Eligibility Information
Case Consultation Notes
Logs (Services, Cases, Other)
Meeting Notes/Minutes
Summary Review Reports
Government Agency Reports
Examples of Utilization Review
FL-2/MR-2 Forms
Logs (Services, Cases, Other)
Meeting Notes/Minutes
Worksheets, Reviews, Reports
Peer Review Documentation
Benchmarking Data
External Agency Reviews
Morbidity & Mortality/Sentinel Event Information
Risk Management Review Information
Examples of Research Information
IRB Reports
Campus Reports
Sponsor Reports
Federal and State Agency Reports
Research Collaborator Correspondence
Correspondence with other Providers and Facilities
Correspondence with Human Subjects
Notebooks/Lab Books
Financial/Accounting Records
Meeting Notes
Institutional Review Board Approvals