Western Governor's University
Legal and Ethical Considerations
Addendum: Release of Information: Shadow Chart Policy Shadow charts should only contain copies of the original records. Shadow charts are maintained to assist ancillary departments in treating patients. An original record is created after each treatment for the primary record and a copy can be made for the shadow chart only for convenience in providing care. Original records are not to be kept in shadow charts. Shadow charts should only contain copies of the original records. This is to ensure that all original documentation is always placed in the main chart. The purpose for this is to have the most up to date documentation in the main chart at all times and not in an ancillary departments' shadow chart that not everyone will have access to if needed. Shadow charts are to be stored away in locked cabinets with limited access to maintain confidentiality of health information. Shadow charts contain protected health information as well and the safety and security of this information should be secured in the same manner as the main record. A2. Information Technology (IT) Staff
IT staff can diminish security breaches by developing effective ways to teach clinical staff about securing their workstations when not in use. Mandatory in-service and power point presentations would be an effective way to do this. The importance of workstation security, not accessing another employee's computer while in use and not using another employee's password should be discussed. Along with how doing so would be in violation of company policy and the HIPAA Privacy Act. Disciplinary action should also be discussed. B. Criminal Liability
A situation from Montana Code 41-1-402 that may result in criminal liability to the organization if not followed correctly is (d) which basically states that a minor may consent to health care...