Practice Brief: Managing Health Information Relating to Infection with
the Human Immunodeficiency Virus (HIV) (Updated)
Acquired immunodeficiency syndrome (AIDS), caused by the human immunodeficiency
virus (HIV), has become a major public policy issue in the US. This is
due, in part, to its significant potential for invasion of privacy and
resultant discrimination. The healthcare community must constantly balance
its duty to protect third parties from the spread of the disease with
its duty to protect the privacy of individuals who are infected with HIV.
Individuals tested for HIV and/or treated for AIDS must be assured that
information shared with healthcare professionals will remain confidential.
Without such assurance, patients may withhold critical information that
could affect the quality and outcome of care, safety of healthcare workers,
and reliability of the information.
Recommended Procedures
To protect patient privacy and the confidentiality of information relating
to HIV infection, the American Health Information Management Association
(AHIMA) recommends the following steps:
- Screening programs should be designed to provide confidential testing
of individuals and communication of their test results.
- Specific, written informed consent should be obtained from the individual
or the individual's legal representative prior to voluntary testing.
(Note: State law may permit testing of a patient without consent if
a healthcare worker has been exposed to the patient's blood or bodily
fluids. In such cases, the incident of exposure and the need for HIV
testing should be discussed with the patient or the patient's legal
representative before the test is done.) Pre- and post-test counseling
should be provided by a qualified healthcare professional.
- Health records of patients infected with HIV should be maintained
with the health records of other patients in a secure area with restricted
access. Special handling procedures should be avoided, as they are more
likely to call attention to the patient's HIV status than routine handling
methods. (Note: In some states, the law may require that HIV antibody
test results be maintained in a special manner. Each provider must be
aware of the applicable laws of the state and adopt policies that conform
to them. In some states requiring special handling of HIV antibody test
reports, the HIM department or responsible individual may need to adopt
a procedure of marking such records in an obscure manner to prevent
the inadvertent release of information on HIV antibody tests.)
- Each facility should implement clear policies and procedures for disclosure
of health information related to HIV/AIDS and ensure consistent compliance.
Generally, information on HIV infection and/or AIDS is reportable to
local health authorities. Depending on state law, the facility may be
required to report the name of the person tested or other identifying
information. Within the facility, a patient's serologic status should
be disclosed only as needed for diagnosis, management, or treatment.
Others who may review patient health records for administrative purposes
(such as quality improvement, billing, and risk management) must ensure
that this information is handled in a confidential manner. Information
should only be disclosed to other legitimate users (including through
the billing process) with specific written authorization of the patient
or the patient's legal representative or upon receipt of a valid subpoena.
(Note: Some states require a court order for release, thus protecting
the records of HIV/AIDS patients from discovery by subpoena.) Information
disclosed to authorized users should be limited strictly to that required
to fulfill the purpose stated on the authorization. Authorizations for
the release of "any and all information" without specifically mentioning
HIV or AIDS should not be honored. Due to the sensitivity of this information,
it should not be transmitted via facsimile machine or disclosed over
the telephone unless urgently needed for patient care. It has become
common practice to request that all pre-natal patients be tested for
HIV/AIDS. Since the increase in this practice, HIM practitioners need
to be increasingly aware of state laws pertaining to HIV/AIDS test results
and their disclosure practices. These tests may be conducted during
the pre-natal care or at the hospital at the time of delivery in some
instances. In any case, the test results should be handled in the manner
stated in your facility's policy and procedures on maintenance and disclosure
of HIV/AIDS health information. Redisclosure of information relating
to HIV/AIDS should be prohibited, unless otherwise required by state
law.
- HIV-positive healthcare workers should be managed according to guidelines
outlined by the Centers for Disease Control and Preven-tion and state
and federal laws. The healthcare worker's privacy must be balanced against
the risk of transmission to patient, employees, and others. If questions
arise, the facility's legal counsel should be involved in resolving
the related questions.
- Medical coders should only code from diagnoses listed in the medical
record. The physician should be consulted prior to assigning codes from
laboratory data or test results when a diagnosis is not clearly stated.
For more information, please refer to the AHIMA publication HIM
Practice Standards: Tools for Assessing Your Organization (1998).
References
Brandt, Mary D. Managing Health Information Relating to HIV Infection.
Chicago, IL: American Health Information Management Association, 1994.
Brandt, Mary D. HIV and Confidentiality: Guidelines for Managing Health
Information Relating to HIV Infection. Chicago, IL: American Health
Information Management Association, 1997.
Prepared by
Jennifer Carpenter, RRA, HIM practice manager
Originally prepared by Mary D. Brandt, MBA, RRA, CHE
Note: This practice brief replaces an earlier practice brief issued
in February 1997.
Issued May 1999
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