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Confidentiality of Social and Medical Information

Confidentiality of Social and Medical Information

Date Implemented: Date Reviewed/Revised: Reviewed/Revised By:


The facility should keep confidential all information contained in a resident’s records,
regardless of the form of storage or location of the record, except when release is required
due to a transfer to another health care facility, or by law.

“Keep confidential” is defined as safeguarding the content of information including written

documentation, video, audio, or other computer stored information from unauthorized
disclosure without the consent of the individual and/or the individual’s surrogate or

Policy Explanation and Compliance Guidelines:

1. Employees should discuss confidential information about residents, only during the
course of business with other employees or contracted professionals, on a “need to know”
basis. Information regarding one resident should not be shared with other residents or

2. Employees should not discuss resident information in public or semi-public areas.

3. To maintain confidentiality of a resident’s social and medical information, facility staff

should exercise caution during discussions with the resident, during discussions with
other employees and/or contracted professionals, in using medical record information for
documentation purposes, and in the use of signs or care reminder information that may be
posted in a residents room.

4. If there is information considered too confidential to place in the record used by all staff,
it may be retained in a secure place in the facility. The record should show the location
of this confidential information.

5. Unauthorized persons are permitted to review records, only with the signed permission of
the resident, or a legal document allowing such access.