CMS Clarifies Permissible “Incidental Disclosures” of Patient Information

March 28, 2012 | Strategic Insights for Health System


A hospital is not required to eliminate all unintended disclosures of medical records and related information provided that the unintended disclosures are secondary to permissible uses of the records and the hospital has taken reasonable measures to limit disclosures to the minimum amount necessary, according to a March 2, 2012, letter to State Survey Agency Directors from the Centers for Medicare and Medicaid Services (CMS). Such incidental uses include placing signs at the bedside or outside patient rooms indicating that a patient is at risk for falling, displaying patient names on the outside of charts, or using whiteboards to list patients present on a unit or in an operating suite.

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