Documenting Safely
What should NOT be put in the chart?
Simply put, HIPAA laws are still in place, which means any health information that might identify a specific individual is protected by the law. That said, experts advise that, as much as possible without hindering clinical care, providers AVOID COLLECTING OR RECORDING immigration-related information.
TX and FL now have policies that require hospitals to ask patients about their immigration status. Even in those states people can decline to answer and providers cannot make access to care depend on their response.
HIPAA & the Medical Record
HIPAA does not protect PHI against all disclosures.
HIPAA permits, but does not require, disclosure to comply with legal processes such as court orders, subpoenas, or warrants. The exception allows only the minimum necessary information to be disclosed to fulfill the legal requirement. It further places specific limitations on information disclosures in administrative proceedings.
Providers should refer law enforcement disclosure requests to counsel and advocate for a policy of nondisclosure where possible. See the HHS resource and other resources below for more details.
More Information
PHI, Law Enforcement, & The Fourth Amendment


US Department of Health & Human Services
When does the Privacy Rule allow covered entities to disclose PHI to law enforcement officials?
Reviews conditions when a provider is required to release PHI
National Immigration Law Center (NILC)
Know Your Rights, Know Your Patients' Rights
Guide to providing information to law enforcement
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