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Provider Resources: Documenting Safely

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.

HIPAA & The Chart:


HIPAA isn't a blanket privacy law, and providers are required to disclose PHI without a patient's consent for judicial proceedings, administrative proceedings, and law enforcement activities (
a warrant is required).

THUS, information in a patient's medical record is NOT completely safe.

What Should Not Be Put in the Chart ?