Working in the healthcare industry means keeping track of lots of information. When you’re working with patient records, it’s vital that you label everything correctly to avoid any mix-ups, all while adhering to HIPAA regulations. While you should always check your clinic’s policies to get the final word, here are some general rules for how to correctly label your patient files.
HIPPA limits the information you can put on the outside of a patient’s file. If you put a lot of sensitive information on the exterior and happen to leave the folder out in plain view, a stranger could snoop through a patient’s history without ever having to touch the file. Some people don’t want aspects of their health shared with even their close family members.
HIPAA protects patient privacy in situations like the one listed above. Here is a list of things that are permitted on the outside of a folder.
You need a way to identify whose folder you’re looking at. Some clinics prefer to use numbers to further protect patient privacy, while others believe that using someone’s name is more personal. Both are allowed under HIPAA. Whenever possible, make sure to include the patient’s full name so that you won’t confuse it with similar names.
Because a patient may have visited multiple clinics, it’s always a good idea to put your clinic’s name on the file. If all your patient’s files should ever be in the same room together, you’ll know which belongs to your clinic.
If a patient has a serious allergy, you are allowed to put a solid-color sticker on the outside of the folder. This doesn’t mean you can color-code for different allergies—use one color to indicate whether an allergy is present, not the type of allergy. For extra patient privacy, avoid stickers with the word “allergy” so that the public remains ignorant of the sticker’s meaning.
When To Color Code
One thing to remember about labeling patient files correctly is that you are allowed to separate old patient files from current patients. In this situation, it might be helpful to use colored labels to designate decades or other chronological markers.
Keeping It Neat and Tidy
When you’re labeling patient files, always write in a clean, easy-to-read script. Cursive and other stylized handwriting are not as easy to read and may lead to mistakes. Always put stickers and labels in the same place on each folder so that you know where to look for them.
We hope this guide to labeling patient files has been helpful. Remember to always double-check HIPAA regulations and follow other best practices set by your clinic.