Transcription Standards of Privacy (107.016)

Transcription Standards of Privacy (107.016) - Policies, Administrative, UWMF, UWMF-wide, HIPAA/Privacy


University of Wisconsin Medical Foundation
Transcription Standards for Privacy
Policy & Procedure

Policy Name: Transcription Standards of
Policy Number: #012

__X__ New ____ Revised

If Revised, Supersedes Policy Dated:

Effective Date: April 14, 2003
Approved By: Peter H. Christman

Title: Executive Vice President

I. Purpose
To define a privacy standards of conduct for the Transcription Department in compliance with
federal and state law as well as other University of Wisconsin Medical Foundation (“UWMF”)
privacy policies. These standards ensure that all patient Protected Health Information (“PHI”) is
held and used by the Transcription Department staff in a private, confidential, and secure
manner, and that PHI is not otherwise inappropriately disclosed.

II. Policy
All PHI is held and used by Transcription Department personnel in a private and secure manner
in accordance with the procedures set forth below. PHI is used and accessed only to the extent
minimally necessary to complete the task at hand.

III. Procedure

A. General Procedures - All Transcription staff abides by the following procedural
requirements relating to the confidentiality of patient PHI.

1. Access – Non Staff. Non UWMF staff is not allowed, under any circumstances, to
access a staff computer at any time.

2. Access – Non Staff. Non UWMF staff is not allowed, under any circumstances, to view
transcription information.

3. Access – Non Staff. Non UWMF staff is not given access to and does not listen to

4. Access – Staff. Staff does not listen to dictation nor access or read transcription already
entered into the system unless such access is absolutely necessary to carry out tasks
related to transcribing dictation currently in process. If such access must take place, staff
accesses no more than is reasonably and minimally necessary to carry out current tasks in


5. Dictation. Dictation is transcribed using earphones in order to protect the privacy of the
patient information being transcribed. An exception to this standard is made only in the
following situations:

(i) The dictation is difficult to hear or understand;

(ii) For purposes of collaboration to transcribe correctly what has been dictated; and

(iii) For training purposes.

In those cases where there is no alternative to playing dictation out loud, the volume is
kept at the lowest volume possible to facilitate the purpose at hand, and in no event is the
patient’s name ever played out loud.

6. Discussion /Minimum Necessary. Staff does not discuss dictation/transcription
activities that do not directly apply to their job duties and current assignments.

7. E-mail. All e-mail regarding patient information is sent through Groupwise. PHI is not
sent outside the Groupwise system unless properly encrypted. In order to determine if
encryption is possible and for other assistance, staff contacts the IS Support Center.

8. Passwords. Passwords are not shared. Passwords are not in use any longer than three
(3) months, and are changed no less than every three (3) month period.

B. In House Transcription Staff – In House Transcription Staff is that staff that performs
transcription services at a UWMF office site. The In House Transcription Staff performs job
duties in accordance with the general privacy obligations outlined in paragraph A, above, as
well as in accordance with the following requirements:

1. Access - Department. Signs are placed prominently along the perimeter of the
department advising others not to pass through the department without escort or except
for purposes of department business.

2. Access - Department. Family members of employees are not allowed in the department
for any reason, except for legitimate department business or in the event of emergency.
Family members are met and/or wait in the reception area or break room.

3. Documents. Documents containing PHI are turned over or put away before staff leaves
her/his desk.

4. Documents. All phone sheets, schedules, and other documents containing PHI are put
away and locked in a file cabinet, desk drawer, or otherwise secured at the end of each

5. Documents. All HIP/EPIC correction sheets are placed face down in the collection
basket and filed in a locked file cabinet at the end of each day.

6. Documents. Staff empties all recycling boxes into a secured shredding bin at the end of
each day.

7. PC Use. All PC screens containing PHI or leading to access to PHI are minimized or
locked prior to staff leaving their desk for any reason. In order to minimize or lock the
PC screen the following procedures are utilized:

(i) Minimize - Press “Windows Key” + M;

(ii) Minimize - Right-click in the Windows Task Bar (along the bottom of the screen)
and select “Show Desktop” or for older “OS's” this would be “Minimize All” key;

(iii) Lock PC – Press “Windows Key” + L, and a password will be required to get
back to the active screen.

8. PC Use. All PC screen savers are set to the minimum time out available for the system
and in no event greater than five (5) minutes.

9. Printers /Fax Machines. The last person on duty in the evening collects and securely
distributes all documents present at printers and fax machines, and turns off all printers
and fax machines before leaving the department at the end of the work day.

10. Telecommunications. Front line phone staff use only Medical Record Numbers
(“MRN”) when identifying patients to outlying sites.

C. Telecommuters - Telecommuter Transcription Staff is staff that performs transcription
services in the homes from a remote site. The Telecommuter Transcription Staff performs job
duties in accordance with the general privacy obligations outlined in paragraph A, above, as well
as in accordance with the following requirements

1. Workstations (including computer, hard drive, screen, keyboard; desk/work area).

(i) Location. The work station is segregated or separated in some fashion from
common traffic areas in the home. [For example, if the work station is placed in a
family room, it is placed off in a corner not regularly used by other family

(ii) Location. The computer monitor is always situated so that the screen faces away
from or is otherwise shielded from the public areas of the home or from plain
view when others are present.

(iii) Log Out. Whenever from a work station, staff logs out of all UWMF
applications, access to UWMF applications is locked (“Windows Key + L) and/or
secured through use of keyboard combination plus password, and the computer is
secured to prevent inappropriate access by others.

2. Phone /Telecommunications.

(i) Dictation. Dictation is never played out loud nor played without headsets except
for purposes of deciphering dictation that is difficult to understand or in the event
of a medical need. If, under these exceptions only, dictation is played out loud
and without headsets, then staff ensures that no third party is in the same room nor
in any other location in the home where there might be the possibility that the
dictation being transcribed could be overheard.

(ii) Dictation. Should dictation be difficult to understand and decipher, telecommuter
staff collaborates only with other UWMF staff for the purpose of deciphering
difficult dictation.

(iii) Dictation. Staff does not leave a dictation “live,” when leaving the work station.
In this situation staff completes the dictation or “rejects” the job to send it back to
the system.

(iv) Calling In. When calling in corrections or other types of difficulties with specific
dictations, staff uses the medical record number, and does not use the patient’s
name to identify the dictation.

(v) Dictation. Dictation from the UWMF system is not re-recorded.

3. Paper /PHI.

(i) Any paperwork or notes including, but not limited to, physician schedules,
handwritten notes, “Post-It” notes, daily personal production “logs,” and corrected
copy forms, or any other media containing PHI is locked away when not in use.

(ii) All logs or other records containing PHI, which are not otherwise filed in the
central record, are retained for no more time than is necessary to complete the
task at hand or for three (3) months, whichever is the lesser period of time.
Following such retention period, all such documents are shredded.

(iii) Any disposed paper or other media containing PHI is shredded or disposed of in
accordance with the UWMF “Disposal of PHI” policy. (e.g., in a UWMF secured
bin, shredding paper, or through Information Services for electronic media or

(iv) Transcribed dictation is not downloaded nor saved from UWMF systems to a
personal computer for any purpose, unless express permission is given by the

Transcription Manager, the Director of Medical Records, or the Privacy Officer.
Transcription is printed for any purpose other than to complete a transcription
assignment and is shredded immediately after such use.

D. Assistance. Additional assistance in determining the appropriateness of responding to
requests for disclosure of patient PHI include the following resources:
 Transcription Manager
 Director of Health Information Management
 Privacy Officer

E. Resources.
 Disposal of PHI Policy

IV. References
 Transcription Department Personnel

V. Attachments
 None

VI. Author & Review

Sponsor: HIPAA Steering Committee
Author: Lisa Arndt Carol Skotzke
Claudia Sanders Amy Whitcomb
Review: Transcription Work Group Clinic Ops Privacy Work Group
HIPAA Steering Committee
Training March 26 & 27, 2003 Transcription Teams
Committee Approval: Transcription Work Group Clinic Ops Privacy Work Group
HIPAA Steering Committee Senior Management Team

Approved: August 4, 2003
Peter H. Christman