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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of
University of Wisconsin Hospital and Clinics and University of Wisconsin Medical Foundation.
Policy Title: Privacy Status and Pseudonym (alias) Patient name Requests
Policy Number: 1.44
Effective Date: April 1, 2016
Patients are typically admitted to the hospital using their legal name. UW Health has established policies
for the approved use and disclosure of personal health information (see UWHC Administrative Policy
4.13-Using & Disclosing (or Releasing) Protected Health Information) in addition to related well defined
hospital work rules to protect the identity of a patient who has been admitted to the hospital under very
specific circumstances. Whenever possible, patients will be encouraged to maintain their anonymity
through the use of the Privacy Status.
A. Privacy Status - Four privacy status options have been established. These statuses should be used
to accommodate patient requests to limit phone calls, visits or listing their name in the hospital
directory. Admissions and Guest Services staff are able to add and revise these statuses
(Admissions: 263-8770 or Guest Services 263-8591 at University Hospital and 234-6700 at The
American Center). For afterhours changes the Emergency Department (262-2398) should be
contacted at University Hospital and (440-6252) at The American Center.
1. No Visitors (NV): When the privacy status of No Visitors is used, visitors presenting to
the hospital will be told that the patient requests no visitors at this time and no room
information will be provided. The patient will however receive deliveries and mail while
they are admitted to the hospital. Hospital staff will give out the patient's phone
number. If a patient would like to receive select visitors, the patient will be responsible
for providing that information to the visitor(s) directly. Hospital staff will not be
responsible for screening approved visitors or keeping an approved visitor list.
2. No Telephone Calls (NT): If the privacy status No Telephone Calls is requested, the
presence of the patient within the hospital will be acknowledged when someone
inquires. The patient's room number will be disclosed but not the room phone number. If
a patient would like to receive phone calls from select callers, the patient will need to
give the number directly to the family member or visitor.
3. No Visitors, No Telephone Calls (NN): If the privacy status No Visitors, No Telephone
Calls is requested, staff will acknowledge the presence of the patient, but the patient will
not receive any visitors or phone calls directed by hospital staff. If a patient wants to
receive select visitors or phone calls, the patient must provide their room number and
phone number directly to the visitor. Hospital staff are not responsible for screening calls
or visitors if the patient has requested no visitors and no telephone calls.
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4. Confidential (CF): Choosing the privacy status of Confidential during a hospital stay will
result in the stay being kept completely private. Hospital staff will not acknowledge the
presence of the patient within the hospital to any visitors, callers or anyone inquiring
about the patient.
B. Pseudonym Name - Requests will be granted for the following reasons:
1. Hospital Security Requests
2. Law Enforcement Requests
3. Victim of Crime
a. Extraordinary circumstances should be discussed with the Access Services
Director or Manager.
b. Pseudonym names will not be used for Outpatients. UW Health employees will
not be granted an alias name unless they fit into one of the categories listed
C. Confidential Patient Status and Pseudonym Name Requests - There may be unique circumstances
(typically requested by law enforcement) necessitating the use of the confidential status on a
patient with a pseudonym name. In these situations the guidelines for confidential patients will be
followed as well as the guidelines for pseudonym patients. In the case of a confidential
patient/law enforcement (LE) patient, Security is typically involved and should be notified
immediately regarding any suspicious inquiries about the patient.
III. PROCEDURE - Pseudonym Name Requests
A. Admissions, Emergency Department Coordinators and Health Information Management (HIM)
will have the security to revise the patient's name. Staff will change the patient's first and last
name in Health Link. The confidential name field will be updated to document the legal name of
the patient. In Health Link when a patient's name is updated, a reason is required. In this case it
would indicate "pseudonym name."
B. Upon execution of this procedure, the patient will be made aware of the following points:
1. The pseudonym name will be in effect for the current admission only.
2. The name will be changed back to the real name upon discharge.
3. The above procedure must be repeated each time the patient is admitted and requests a
4. Friends and family must inquire about the patient room information, parking, housing
referrals, etc. using the pseudonym name.
5. The patient's bill will be generated with the patient's real name.
6. Should the patient request copies of his/her Medical Records, the documents for the
inpatient stay may reflect the patient's pseudonym name.
C. Security to view the pseudonym and real patient names will be limited to the staff with security to
revise the name plus Outpatient Registration, Patient Business Services, Med Flight, Access
Center, Coding, Case Management and Resource Center staff. The patient's real name will not be
interfaced to ancillary systems. The patient's wristband will indicate the pseudonym name.
Should clinical staff require historical medical information for the patient which is unavailable in Health
Link, they should contact HIM.
Upon discharge, Admissions will be responsible for removing the pseudonym name and entering the
correct legal name.
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Sr. Management Sponsor: Chief Financial Officer
Author: Director, Access Services
Approval Committee: UW Health Administrative Policy and Procedure Committee
President, University of Wisconsin Hospitals
Chief of Clinical Operations
Previous revision: 012013
Next revision: 042019