In clinical documentation, we see eight HIPAA violations more often than any others:
- Picking the wrong CC on an email containing protected health information
- Picking the wrong patient name
- Picking the wrong dictator
- Picking the wrong account number, medical record number or subject ID
- Entering the wrong supervising or attending physician
- Sharing information about a patient with others who have no reason to have it
- Failure to immediately report any potential breach or security incident to the compliance officer or your supervisor
- Improper disposal of materials containing protected health information.
And there’s one other mistake that needs to be mentioned: going into a patient’s chart for no reason. While it’s not a common violation, it’s a serious one. Even employees who have rightful access to a patient’s chart can’t look at it without a valid reason. And while they usually know that, it bears repeating often because it’s the kind of thing that gets all types of workers, from MTs to nurses, doctors and administrators, into trouble.