/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/uwhc-wide/,/policies/administrative/uwhc/uwhc-wide/medical-records/,

/policies/administrative/uwhc/uwhc-wide/medical-records/619.policy

201505124

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UWHC,

Policies,Administrative,UWHC,UWHC-wide,Medical Records

Transcription Confidentiality Policy (6.19)

Transcription Confidentiality Policy (6.19) - Policies, Administrative, UWHC, UWHC-wide, Medical Records

6.19

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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: Transcription Confidentiality Policy
Policy Number: 6.19
Effective Date: May 1, 2015
Chapter: Medical Records
Version: Revision
I. PURPOSE

To establish a policy outlining processes and parameters concerning the confidentiality of health
information as it pertains to the transcription process in accordance with the Health Insurance Portability
and Accountability Act of 1996 (HIPAA). This policy is designed to protect the confidentiality and
integrity of confidential health information as required by law, professional ethics, and accreditation
requirements.

UWHC has established the following policy for transcribing, delivering, retrieving or otherwise handling
confidential healthcare information as it pertains to the transcription process. The term "transcriptionist"
pertains to all persons whose responsibilities and duties necessitate access to audio, electronic or printed
patient information for the purpose of carrying out the transcription process. This policy and procedure
applies to all transcriptionists employed by UWHC, UWMF, and UW-Madison who participate in the
transcription process. This policy and procedure also applies to any organization outside UW Health that
holds a contract with UWHC to provide transcription services.

One responsibility of each transcriptionist is to maintain the confidentiality of the content of the
documents transcribed or Health Link documents used as a reference. Transcriptionists will access only
that information needed to complete their work (reference Hospital Administrative Policy 6.30-Minimum
Necessary Rule). Transcriptionists therefore, should maintain constant awareness of situations that would
cause a possible breach of confidentiality and avoid such situations.

II. POLICY
A. Applicability: All elements of this policy are applicable to the transcription of UW Health patient
medical reports regardless of location. This encompasses work carried out within the UWHC as
well as work carried out at outside locations including, but not limited to, the work stations of
home-based workers.
B. Confidentiality Agreement: A Transcriptionist may utilize the transcription system only after
signing a statement signifying that the transcriptionist understands and acknowledges his/her
obligation to protect and maintain confidentiality when taking part in the UWHC transcription
process. The signed statement will further indicate that the transcriptionist agrees to fulfill his/her
obligations as they pertain to security of information. Finally, the signed agreement will indicate

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that the transcriptionist understands that disciplinary action (in accordance with hospital policy)
will result if he/she does not comply with any or all aspects of this policy. The employee's
immediate supervisor will be responsible for annually obtaining and maintaining these records.
C. Limitations of Access: Transcriptionists, by role, work with patient information and may
therefore access any dictation that is sent to them for transcription. They may also access related
information concerning patients whose reports are being transcribed in order to fill in missing
information and resolve ambiguities. There is usually no reason for transcriptionists to be
accessing information concerning other patients, so the transcriptionist must be able to show how
his/her UWHC related responsibilities require access to any other information.
D. Training and Authorization: Proper and complete training helps assure the security and loss
prevention of essential and privileged healthcare information; therefore, transcriptionists will be
allowed access to the UW Health electronic medical record, UWHC network, dictation system
and transcription system only after proper training has been completed. Transcriptionists will be
held responsible for activity tracked to them through transcriptionist identifying information.
Thus, no transcriptionist of the electronic record, network, dictation system or transcription
system shall share his/her access codes with any other person, whether or not that person is an
employee of UW Health. The employee's direct supervisor will be responsible for issuing
department-specific passwords and transcriptionist codes. Other passwords and transcriptionist
codes will be issued by the IS department as necessary.
E. No Right to Privacy for Transcriptionists: The transcription system and all transcribed data are
the property of UWHC. Consequently, transcriptionists have no right to privacy in utilizing the
dictation system and/or transcription process. UWHC reserves the right to monitor, audit and read
transcribed documents. The network administrator may override access codes and transcriptionist
passwords. UWHC may monitor the content and usage of the dictation and transcription system
to support operational, maintenance, auditing, security and investigative activities.
F. Protection of Patient Identifying Information: Transcriptionists shall, at all times, take measures
to protect the identity of patients. These measures include, but are not limited to:
1. When possible, thoroughly eliminate the readability of the patient's name from reports
retained for quality and/or reference purposes;
2. Refrain from communicating or sharing in any form, the details of a patient's healthcare
record (whether or not using the patient's name) to persons not involved in the patient's
healthcare or transcription process; and
3. Avoid use of patient identifying information in e-mails or phone calls that can be
overheard by unauthorized persons.
G. Secure Environment:
1. Audio playback: Dictation in audio form carries the same measure of confidentiality as
the finished transcription product; therefore, headphones are the preferred tool for audio
playback. Transcriptionists shall assure that only those persons authorized by UWHC to
handle the patient's record have the ability to hear audio playback of information. For
example, before transcriptionists can listen to dictation through a speaker phone instead
of an earphone, they need to assure that unauthorized persons cannot overhear the
speakerphone.
2. Computer monitors: Information viewable on a computer monitor carries the same
measure of confidentiality as the finished transcription product; therefore,
transcriptionists shall assure that only those persons authorized by UWHC to handle the
patient's record can view the transcriptionists computer monitor while confidential
information appears. For example, when the transcriptionist must leave the workstation,
the transcriptionist should log out of access to confidential information and lock their
workstation. To ensure security of the equipment when not in use, logins and passwords
should never be posted or kept in a place accessible to others (reference Hospital
Administrative Policy 1.02-Access to Electronic Information Systems).

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H. Electronic Transmission of Information: No transcriptionist may electronically transmit
transcribed data except as authorized by the Transcription Manager, consistent with relevant
system security policies. All such transmissions must meet relevant UWHC security policies.
I. Authentication of Report: The initials of the transcriptionist shall appear on all reports for
tracking and quality purposes. This marking, however, does not constitute the formal
authentication of the report required by law and professional standards.
J. Release of Data: transcriptionists are not authorized to release information to anyone outside
UWHC. Release within UWHC is limited to (a) the persons who dictated the material and their
supervisors, (b) the transcriptionists' supervisors, or others to whom those supervisors authorize
them to release information. Requests to release information to others should be referred to
Health Information Management.
III. COORDINATION

Senior Management Sponsor: VP, Chief Information Officer
Author: Director, Health Information Management
Reviewer: Medical Records Committee

Approval Committee: Administrative Policy and Procedure Committee

Signed by

Ronald Sliwinski
President & CEO


Revision Detail:

Previous revision: 052012
Next revision: 052018