Download Confidentiality Agreement

UCSD Medical Center
Confidentiality Statement for Clinical Education Observers
The Federal Health Insurance Portability and Accountability Act (HIPAA), the State of California
Confidentiality of Medical Information Act (CMIA, SB541, AB211) and related laws and
regulations were established to preserve the confidentiality of medical and personal information,
and to specify that such information may not be accessed, used, disclosed or viewed except as
authorized by law or unless authorized by the patient. These privacy laws and regulations apply to
all Health System personnel including students and observers. All students / observers are required
to agree to and sign this confidentiality statement.
I understand that as a clinical education observer, that I am not permitted to have direct patient
contact or to practice medicine. I acknowledge that I do not have medical staff privileges to practice
medicine at the University of California San Diego Health Systems. I understand that as an
observer, I am not permitted to participate in direct or indirect patient care activities. These
restricted activities include but are not limited to: hands-on patient care or medical equipment,
access to medical information (medical charts, computer work stations, electronic medical record),
instruments, medications, infusions, intravenous liquids, lab testing equipment, etc.
I understand that, as an observer for clinical education purposes, I may see or hear confidential
information, such as medical information about a patient, verbal discussions about patient care, and
electronic communications that include confidential patient information.
I acknowledge that it is my responsibility to respect the privacy and confidentiality of patient
information and other personally identified information. I will not access, use, or disclose any
confidential information outside of my educational experience at UCSD. I will not photograph,
videotape or photocopy any patients or patient information. I understand that I am required to
immediately report any information I may have about the unauthorized access, use, or disclosure of
confidential information to the UCSD Health Sciences Privacy Office (phone 619-471-9150).
I understand that if I breach any provision of this Agreement, I may be subject to civil or criminal
liability under HIPAA and under State of California laws (AB211 / SB541) as well as personal fines
and civil action.
I will wear the ID badge issued by UCSD Medical Center Security at all times on UCSD Health
System’s premises.
Observer’s Name / Student’s Name (Please Print):
Observer’s Signature / Student’s Signature:
Date: __________
*****
(If student is under 18 years of age, then parent / guardian signature is needed as well.)
I am the parent / guardian of the student named above and I agree to be responsible for my child’s
inappropriate access, use, or disclosure of confidential information during his/her participation at
UCSD.
Parent / Guardian Name (Please Print):_________________________________________
Parent / Guardian Signature:_______________________________ Date: ______________
Record Retention: Route the completed form to the UCSD Medical Center host department to retain on file for 6 years.
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6/19/2017
Code of Conduct for Clinical Education Observers
The following activities are not permitted by Observers:
1. Practice of medicine
2. Hands-on patient care or hands-on … medical equipment, monitors, instruments,
medications, infusions, intravenous liquids, lab testing equipment, etc.
3. Medical record charting, dictation, transcription or photocopying patient charts or other
materials identified with patients’ names or identifying information, or maintaining
private log books with patient identifying information.
4. Independently accessing patient information (electronic or written) or restricted areas of
UCSDMC or any of its affiliates.
5. Billing for services
6. Wearing a white coat or white jacket. White coats / jackets may cause you to be
misrepresented as a resident /fellow, medical student or staff physician.
7. Writing orders for patients or making verbal orders for patients.
8. Personal photography, videos, recordings, filming, texting or audio recordings.
9. Conducting clinical trials or gathering data in preparation for clinical trials or research
publications. Clinical trial personnel must be registered with a UCSD IRB approved trial
and wear their employee identification badge.
10. Provision of free items, pharmacy samples and/or marketing materials to staff or
patients. UC Health Care Vendor Relations policies prohibit distribution of free items to
UC personnel, e.g., pens, pads, coffee mugs, lunch, beverages, branded promotional
items, etc.
11. Storing food or beverages in patient care areas or clinic refrigerators is not permitted.
Eating / drinking in patient care areas is not permitted.
12. Smoking on hospital premises
Reminders:
13. Cell phones: Turn off cell phones or turn the cell phone ringer to vibrate setting. Step
outside patient care areas if you must answer a cell phone call.
14. Photography: Personal photography, tape and video-recordings are not permitted.
15. Wash hands -- after leaving each patient’s room or treatment area. Use the gel
dispensers located throughout the UCSD Medical Center.
16. Comply with all hospital rules, regulations and policies and procedures (MCPs).
17. Comply with orders and directions of the attending physician / health care practitioner
and hospital nursing staff including leaving the area, if necessary.
18. Observers may not see or interact with patients individually. The treating provider must
inform the patient about the presence of an observer and ask permission to permit the
individual to observe the patient’s care. If permission is refused, the observer is to
leave the area.
19. Observers may not provide medical care, may not take a medical history, may not
examine a patient, may not provide medical advice to a patient, or may not assist in
surgery or other medical procedures.
20. Written consent must be obtained from the parent or legal guardian of minors under the
age of 18 who request to observe patient care, unless the minor is a UCSD medical
student.
21. Observers and Visitors in Clinical Areas - are expected to maintain appropriate attire for
the business environment. For safety reasons, closed toe shoes are preferred.
- Informal attire, such as shorts, jeans, workout attire, tank tops, torn or sheer
clothing, beach sandals are not appropriate.
873991534
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