Send a confidentiality disclosure with the fax. Every fax of part of a chart carries a line saying the pages are privileged and confidential. It adds that the pages are meant only for the addressee. It asks anyone who gets the fax by mistake to tell the sender at once. Lab results and operative reports are faxed often, so this wording lives on the office cover sheet. You send it with every batch of pages.
The point is that a fax can go astray. One wrong digit sends the record to a stranger's machine. The disclosure warns that reader and gives you a way to get the pages back. The signed records release is a separate safeguard. It is the patient's permission to send the chart at all, and it is kept in the office. Adding more of her identity to the pages does the opposite of protecting her. A Social Security number or a date of birth on every sheet only widens the harm if the fax lands in the wrong place. Also put a dated note in the chart saying whom you sent copies to. That note proves later that the report went out, to whom, and on what day. A printed copy of an electronic chart follows the same rules as paper.
Two rules travel together. Get written permission before records leave the office, and put a confidentiality line on anything you fax. Read the fax number out loud with a second person before you press send. Guarding records this way is part of the COA history and documentation content area.
Incorrect Answers
- A. A Social Security number is prized by identity thieves. Nothing about a fax calls for one. It only raises the harm from a misdial, and the family doctor already knows who she is.
- B. The release is kept by your office as proof of consent. The receiving doctor does not need a copy for the fax to be proper. Sending it adds one more private page to the pile.
- C. A birth date on every page adds more private data to pages that may go to a stranger. It is not the required item, and it does nothing to warn a wrong receiver.
Testing Pearls
- Every faxed record carries a privileged and confidential disclosure.
- The disclosure names the addressee and asks a wrong receiver to notify the sender.
- Records leave the office only after a signed records release.
- Write a dated note in the chart naming whom copies were sent to.
- A printed copy of an electronic health record needs a release too.
References
- American Academy of Ophthalmology. Ophthalmic Medical Assisting: An Independent Study Course. Chapter 19, Understanding Practice Management.
