فرآيند واگذاري اطلاعات بيمار در بيمارستان هاي شهر اصفهان و تدوين دستورالعمل هاي مربوط

Patientʹs Information Disclosure Process in Hospitals of Isfahan and Compiled related Guidelines*

Introduction: One of the most fundamental duties of Health Information Management (HIM) professionals is to maintain health Information about their patients. This duty is imposed explicitly by state and federal statutes and regulations as well as by accreditation standards. Also one of the most important responsibilities of HIM professionals is keeping confidential health information out of the hands of unauthorized users through appropriate policies and procedures, facility and space planning, information systems design and selection, staff education, and other measures. The purpose of this research was to study the health information disclosure process in Isfahan hospitals. Methods: In this descriptive, cross sectional study, the medical record departments of 30 hospitals in Isfahan city were enrolled. A six-section checklist was designed for data collection .The researcher observed and interviewed with medical record staff and complete the checklist. The collected dates were analyzed with SPSS software. Results: 100% of medical record practitioners are alert in regard to health information disclosure laws. When it is needed to use the patientsʹ record in court, all pages of patients file were numbered and copied in 100% and 92.3% of cases. In 69.2% of cases the attorney of patient is authorized to access the patientsʹ record, if he or she was authenticated by the patient. In 76.9% of cases there was no guideline for deliver the patient record to another health care facility. Conclusion: HIM professionals have important responsibility in health care facilities to protect the confidential health information; also they must earn the regulations of disclosure of health information and perform them in their hospitals. Keywords: Information; Confidentiality; Patients; Hospitals; Medical Records. Type of article: Original Article