Describes the circumstances to which the policy responds, or the problem or conflict it resolves.

Published by Jeannie R. Ferrell

Dec 8, 2022


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Module 4 Privacy Policy and Procedures (Domains II.1, II.2, and II.3)
Privacy Policy and Procedures:
Clearly written policies and procedures can assist a manager in many ways. A Policy and Procedure a repeat-use plan that expresses an organization’s general response to a problem or situation. It can facilitate the job of managers and subordinates as well as facilitate the delegation of tasks.
In this assignment you will use all available resources such as your textbook, the Sayles Book, and BoK articles in your Canvas Library and create policies and accompanying procedures to address the following:
1. Authorizations to Release Information
2. Accounting of Disclosures
3. Deposition or Court Appearances
4. Response to Subpoenas
5. Minor Access to Protected Health Information
6. PHI Security Risk Assessments

The purpose of this assignment is to strengthen your knowledge of the rules governing Protected Health Information, apply that knowledge to professional written policies and procedures, and be able to negotiate tasks and work as a team.
Your HIM Department has recently migrated to an electronic health record. With this major change, many long-term staff have chosen to retire from their positions. The policies and procedures for handling protected health information had not been update for several years and the retiring staff held anecdotal knowledge on how to manage patient information. Further, with the new EHR, security measures also need to be included in the policy.
Policy & Procedure Guidelines
Your policies and procedures should all have the same layout. You can make up a hospital name for your group of policies. As a manager, having a detailed and clearly written set of policies and procedures can assist you in achieving consistency of your HIM tasks as well as successful delegation to subordinates. Having a repeat-use policy and procedure that can be handed off to a subordinate will save you time as well as encourage staff to learn new tasks and take on more responsibility. This can lead to significant employee satisfaction and retention.
When you write the procedures, which are essentially a step-by-step guide, be sure the steps can be followed. You may also consider a flow chart for the procedures. Wherever possible, cite your regulatory resources using the appropriate citation format for legal documents. You can use any of the standard formats such as The Bluebook : a uniform system of citation. APA, MLA and Chicago Manual of Style. The ALWD is also a typical citation reference for legal documents.
Use the following format for your policies and procedures:
• Policy Title
o The title of a policy should effectively and briefly convey its content and conform to IPPM editorial standards.
• Scope
o Identifies who and/or what is affected, such as “all divisions, departments and academic units of RIT,” “all regular employees,” or “graduation requirements for all degree programs.”
• Policy Statement
o States the general and specific content and provisions of the policy. Authors are encouraged to state procedures separately unless they are intrinsically tied to the policy itself or unless stating them separately would detract or significantly diminish clarity or ease in understanding.
• Rationale
o Provides the rationale for the policy. Describes the circumstances to which the policy responds, or the problem or conflict it resolves. States any federal, state, or local statutes or regulations related to the policy. If applicable, identifies other related RIT policies.
• Definitions
o To enhance clarity of meaning and accurate interpretation, terms of central importance in the statement of policy should be defined. In policies where the number of such terms is limited, the definitions may appear in the policy statement itself.
o If the number of such terms makes defining them in the policy statement unwieldy or confusing, use a separate section to list and define them. Each appearance of each defined term in the policy statement should then be hyperlinked to the appropriate definition in this separate section.
• Procedures
o States procedures related to the policy. Procedures should, in concrete terms, describe how the policy will be implemented or enforced, the actions or mechanisms related to implementation or enforcement, and the roles accountable for each. If relevant procedures are not included in either the policy statement or a separate procedures section, authors are expected to make them accessible via a hyperlink to the website where they reside.
• Responsible Office(s)
o Provides name of one or more office, department, or group and position responsible for stewardship of the policy and/or maintaining its procedures. Includes all relevant contact information, such as phone, office location, e-mail addresses, and website URL.
• Effective Date
o The effective date of an edited, new, or revised policy is the date of final approval by the applicable governance group or an alternate date agreed upon by the responsible office and applicable governance group.
• Policy History
o Documents the date of initial approval of a policy as well as dates of approved substantive and editorial changes over time. In addition to providing the final version of content in a Word document for a new or revised policy, the responsible office communicates the approval date to Office of the Provost to add during the publishing process.


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