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/policies/administrative/uwhc/uwhc-wide/legal-affairs/416.policy

201505128

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UWHC,

Policies,Administrative,UWHC,UWHC-wide,Legal Affairs

Release of Patient Information to News Media (4.16)

Release of Patient Information to News Media (4.16) - Policies, Administrative, UWHC, UWHC-wide, Legal Affairs

4.16

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Administrative (Non-Clinical) Policy
Category:
 UWHC only (Hospital Administrative-entity wide)  UWMF only (entity wide)
 UWHC Departmental (indicate name)  UWMF Departmental (indicate name)
 UWHC and UWMF (shared)
Policy Title: Release of Patient Information to News Media
Policy Number: 4.16
Effective Date: May 1, 2015
Chapter: Legal Affairs
Version: Revision
I. PURPOSE

To establish a policy for the release of patient information to the news media while complying with state
and federal regulations governing patient confidentiality.

II. POLICY

UWHC will release patient information to the media only to the extent permitted by state and federal law.
Public Affairs, or those authorized by Public Affairs (e.g. Nursing Supervisors, Access Center,
Administrators-on-Call) are the only staff permitted to release any patient information to the media.

III. PROCEDURE
A. Access to Patient Care/Patient Record Areas
1. No member of the news media may enter a patient-care or patient records area without
prior approval by the Public Affairs Department.
a. Public Affairs representative must accompany a member of the news media into
these areas.
b. The Public Affairs representative should be alert for signs of undue fatigue or
discomfort in the patient and may stop the photographing or taping if judged
appropriate.
2. Because the presence of camera crews and equipment is potentially disruptive in these
settings, media access to operating rooms, recovery rooms and intensive care units is
granted only with (1) prior authorization by the Public Affairs Department, (2) prior
written authorization from the patient; and (3) appropriate staff consent.
3. Media access to the UW Hospital emergency room is generally not permitted.
B. Release of "Routine" or "Directory" Information About Adult Patients to the News Media
1. If the patient has been given an opportunity to object, and does not object, and if a
member of the media asks for the patient by name, Public Affairs or persons authorized
by Public Affairs, may release the following information: (1) confirmation of presence in
facility; (2) general condition (e.g. good). At their discretion, they may also release the
fact that a patient is in intensive care. At no time shall direct room numbers or other
inpatient units be disclosed without the written authorization of the patient or legally
authorized representative.

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a. Upon admission, UWHC must inform its patients of the information that will be
stored in its patient directory and to whom that information may be disclosed.
b. The patient has the option to state whether he or she "objects" to the information
released, including confirmation of his or her presence in the facility. If the
patient chooses to restrict or prohibit the release of information to the news
media, the hospital must abide by the patient's decision. The patient's right to
restrict information release includes the right to prohibit confirmation of the fact
that they are hospitalized.
2. If a patient is admitted emergently and/or is incapacitated, and thus has not had the
opportunity to object to release of directory information, hospital staff must exercise
judgment as to whether information disclosure to the news media is in the patient's best
interest. In most circumstances, it is in the best interest of the patient to confirm presence
in the facility and general condition. Any questions or concerns regarding unusual
circumstances must be directed to Public Affairs.
a. If the patient is not given the opportunity to object, hospital staff must consider
any prior expressed preferences of the patient, if they are known, and;
b. When it becomes practicable to do so, patients admitted emergently must be
given an opportunity to object to releases of directory information.
3. Condition reports: Patient conditions may be described with one of the following options:
a. Not yet known (as patient is still being assessed) (for patients awaiting or
undergoing assessment)
b. Good
c. Fair
d. Serious
e. Critical
f. Deceased
C. Release of Non-Routine Information About Adult Patients
1. Public Affairs or those authorized by Public Affairs may release non-routine information
with the written authorization of the patient or the patient's legally authorized
representative. Non-routine patient information includes any information beyond name,
brief condition description, and general location in the hospital. Non-routine patient
information includes detailed statements about the patient's medical condition and
treatment, the nature of the injury or illness, the name of the patient's physician, the
patient's financial/insurance arrangements and the patient's diagnosis and/or prognosis.
2. The following reasons for treatment should never be disclosed or confirmed by Public
Affairs without prior approval from the UWHC Legal Department or the Administrator-
on-call:
a. Mental illness
b. Child abuse
c. Drug or alcohol abuse
d. Suspected or known suicide attempts
e. Rape, sexual abuse
3. There may be some circumstances in which UWHC would not release information to the
media even with the written authorization of the patient or the patient's legally authorized
representative.
D. Release of Information about Minors to the Media
1. When minor patients are able to consent to their own care, the above procedures
concerning adults shall apply.
2. When the consent of the parent or other legally authorized representative is necessary, the
routine or directory information can be released as follows:

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a. Under B.1 when the representative has been given an opportunity to object and
does not object.
b. Under B.2 when the representative has not had an opportunity to object due to
the emergent nature of the admission or the inability to identify or contact a
representative.
c. Consult Hospital Administrative policy 4.17-Informed Consent, to determine
whether the minor can consent, who can act as a representative, what to do when
representatives disagree, and related questions. If the question is not answered
there, consult the UWHC Legal Department.
E. Release of Patient Information in Disaster Situations
When the emergency response plan is activated, Public Affairs is to be notified immediately via
phone and department pager. Special considerations apply to the release of patient information in
disaster situations; all public statements will be channeled through a single source, to the extent
practicable, to be designated by the hospital CEO or designee.
1. Every effort should be made to notify a patient's next-of-kin before releasing any patient
information. However, if such notification cannot be made within a reasonable amount
of time, the hospital may share patient information with other hospitals and/or with
disaster relief organizations before the next-of-kin is notified.
2. Information about patients involved in a disaster may be released only to other hospitals,
health care facilities, and public and private disaster relief agencies (e.g. the Red
Cross). The purpose of sharing this information is to help notify family members or
others responsible for a patient's care.
3. General information may be released to the news media and the public to reduce public
anxiety in highly charged situations, including disasters. This information may, for
example, include the number of patients being treated, a general description of their ages,
genders, etc.
4. If the media or a family member calls for information about a specific patient and
provides the patient's name, routine information may be provided as described in Section
B above.
F. Release of Information--Prisoners and Forensic Patients
Prisoners from Wisconsin state correctional facilities and persons from state mental health
facilities (Mendota and Winnebago Mental Health Institute) are under the jurisdiction of the
Wisconsin Department of Corrections (DOC) and the Department of Health Services (DHS)
respectively. Hospital personnel must refer all media inquiries about such prisoners to DOC and
mental health facility patient to DHS, without acknowledging whether the patient is in
UWHC. Exceptions may be made with the approval of UWHC Legal Department or the
Administrator-on-call after consultation with DOC or DHS.
G. Situations Involving Patient Security
One reason for not disclosing patient information, including confirmation of the patient's presence
in the facility, is that the patient may be endangered by the release. Examples of situations where
this may apply include patients with abusive partners or stalkers and patients who have been
intentionally injured and the suspected responsible person is not in legal custody. When Public
Affairs is aware such factors are present, a determination should be made by Public Affairs in
consultation with the patient or patient's representative, if available, concerning whether
information should be released or withheld. If law enforcement is involved, law enforcement may
also be consulted; Public Affairs should not initiate contact with law enforcement. UWHC Legal
Department and the Administrator-on-call are also available for consultation and Public Affairs
shall follow their directions when they are consulted.
H. Information about Patient Deaths
1. Family Notification:

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a. UWHC may use patient information to notify family members or others involved
in the care of patients about a patient's death.
b. Information about patient death can be released to the media only after the
immediate family is notified and only if the media provides the name of the
patient in question.
2. Cause of Death: Cause of death should not be released. If a case has been in the public
domain and media interest is likely, Public Affairs should confer with hospital attorneys
and the patient's family as to which details may be provided.
3. Time of Death: Date and time of death may not be released.
4. Coroner's Cases: These include accidents, drowning, gunshot wounds, suicides,
homicides, foul play, unexplained or unusual circumstances, and patients who have been
in the hospital less than 24 hours and for whom no medical history can be obtained. If a
death is a coroner's case, the death should not be publicly confirmed until the coroner has
been notified. Inquiries about cause and circumstances of the death should be referred to
the coroner.
5. Name of Funeral Home: If the immediate family has been notified and death is
confirmed, the name of the funeral home receiving the body may be released.
IV. FORMS

Authorization to Use Image/Personal Information in Public Communications (found on U-Connect)

V. COORDINATION

Sr. Management Sponsor: SVP General Counsel
Author: Compliance and Privacy Officer

Approval Committee: Administrative Policy and Procedure Committee

SIGNED BY

Ronald Sliwinski
President & CEO


Revision Detail:

Previous revision: May 2012
Next revision: May 2018