Health Information Compliance Alert

Published on Tue Oct 27, 2009 PDF

Staff members' input is vital to your self-evaluation's success.

Your personnel play a huge role in ferreting out your compliance program's weak spots.

Use this worksheet, created by William Hubbartt of Hubbartt & Associates in St. Charles, IL, to gather input on your compliance program from your department heads and other key staffers. Compare the responses to ensure what compliance problems -- if any -- you've missed.

Name: ______________________________________ Date: ______________________

Department: ____________________________________

1. Describe any security incidents occurring during the period of evaluation (attach copies of Security Incident Reports).

2. Describe any Privacy Complaints occurring during the period of evaluation (attach copies of the complaints).

3. Describe any unauthorized disclosure of protected health information occurring during the period of evaluation (attach copy of any relevant record or documentation of the disclosure).

4. Describe corrective action taken for any incidents recorded in items #1, 2 or 3 above.

5. Describe any facility changes occurring during the reporting period.

6. Describe any equipment or systems or software changes occurring during the period of evaluation.

7. Have there been any personnel or organizational changes occurring during the period of evaluation? If so, describe.

8. Have there been any changes to the HIPAA Privacy or Security regulations? If so, describe them.

Important: Use this worksheet anytime you introduce new technologies or make changes in your organizational structure, Hubbartt advises.