The purpose of this policy is to establish procedures for athletic training students to abide by in regards to medical documentation & medical confidentiality as it pertains to protecting the health information of student- athletes (patients) at Central Connecticut State University, including guidelines for documentation, storage, and dissemination of medical records. Central Athletic Training staff members and athletic training students must understand their responsibility for ensuring the security and upholding confidentiality of healthcare information.
Family Educational Rights and Privacy Act (FERPA - 1974). Federal rules governing the release of student information. FERPA was designed to protect the privacy of "educational records," which were broadly defined to encompass most student health and medical information kept by an institution. Health Insurance Portability and Accountability Act (HIPAA 1996). HIPAA is a federal law enacted to: Protect the privacy of a patient’s personal and health information; provide for electronic and physical security of personal and health information; and standardize coding to simplify billing and other transactions. Therefore, it is imperative that members of the athletic training staff comply with both regulations in order to:
- Assure that health information of the student-athletes (patient) is being protected.
- Allow the athletic training staff to share pertinent health information while protecting the student-athlete’s (patient’s) privacy.
Training Requirements
Athletic training students must complete medical documentation, confidentiality, HIPAA, & FERPA education session annually. Students will be informed of the requirements of HIPAA & FERPA regulations through required training when admitted to the athletic training education program and throughout their clinical field experience courses. Reminders of these requirements will occur regularly at the course level.
Confidentiality Statement of Understanding:
As members of the athletic training staff at Central Connecticut State University there will be times when you will be exposed to confidential and privileged information. At no time should you discuss information in which you obtained as a member of the athletic training staff with others. This includes any information about an patients’ medical condition, the treatment of a medical condition, or any information which you acquire in the locker rooms, athletic training facility, physician's office, or otherwise which is considered to be non-public information.
The unique opportunity that athletic training students have to observe and participate in intercollegiate athletics as a health care professional can and will be terminated if they violate confidentiality. Furthermore, the professional rapport that was established with athletes, coaches, and physicians is jeopardized by this lack of discretion and violation of this code of ethics.
Athletic training students are NOT to disclose any information to anyone i.e. media personnel, professional scouts, administrators, coaching staff members, teammates, including parents. Information may be shared with the head coach only when directed to do so by the head athletic trainer or a designated assistant athletic trainer.
Athletic Training Students annually must sign a statement of understanding of “Central’s Medical Documentation & Confidentiality Policy”, in which the student:
- Will acknowledge education on:
- Medical Documentation
- Access & Release of Medical Information (including Medical Release for Case Studies)
- Medical Record Storage & Security
- HIPAA and FERPA regulations as it pertain to patient confidentially (on-campus and off-campus clinical field experiences and observations)
- Privacy
- Facility Security
- Agree to practice medical confidentiality according to this policy and federal regulations.
- Understand that violations to this policy will result in immediate suspension from the assigned clinical field experience and the potential for termination from Central’s athletic training education program (ATEP).
Central Athletic Health Sensitive Records
The student-athlete's (patient) medical history, screening information, injury records, injury diagnosis, injury treatment records, rehabilitation records, as well their injury-playing status are considered medical records. Information obtained from any of these medical documents is to be considered confidential.
- Pre-participation Exams & Screening Evaluations
- Medical history, Injury records, Injury Diagnosis
- Injury treatment records
- Physician visits/follow-ups & Diagnostic Reports
- Rehabilitation records
- Injury-playing status
- Phone calls
- Text messages
Athletic Training Students
- Central and all affiliated clinical field experience sites expect the athletic training student to be familiar with HIPAA, FERPA and the Privacy Rule
- Athletic training students are expected to follow these guidelines when accessing information and providing care to patients.
- Athletic training student are held to the same standard as the licensed athletic trainer
- There will be ZERO TOLERANCE to violations to this policy; consequences may result in immediate dismissal from the ATEP
On Campus vs. Off Campus Observations Clinical Field Experiences:
As a student in a health profession program at Central Connecticut State University:
- You are required to abide by the health information privacy requirements of a federal law called HIPAA during any off-campus clinical field experiences (including observations) in which HIPAA regulations are practiced.
- You are required to abide by the health information privacy requirements of a federal law called FERPA during any on-campus (university)/off-campus (high schools) clinical rotation in which FERPA regulations are practiced.
Medical Release for Case Studies
A Medical Release form with the signature of the patient must be obtained for those athletic training students involved in preparing case studies for practicum courses. Forms are available in the athletic training facility. The Medical Release form gives you permission to use the designated information in your written report and presentation. Athletic training students may not remove medical records from the athletic training facility. At no time are the patient's medical records to be photocopied or scanned. All surgical notes and images must remain in the student-athlete’s (patient’s) medical file.
Central AT Guideline 1: Documentation
Athletic training staff members must document patient care and must insure that the information is stored and secured. Confidentiality of all medical information shall be maintained in accordance with the Information Practices Act, the Confidentiality of Medical Information Act, and Central policy. Therefore:
- All evaluations, treatments, rehabilitation programs must be documented and securely maintained.
- All interactions between patients and athletic trainers are to be documented in the medical record of the patient and securely maintained.
- All interactions between athletic trainers and other health care providers are to be documented in the medical record of the patient and securely maintained.
- Phone conversations and text messages will be documented as stated above in the medical record of the patient and securely maintained.
- Athletic Training students are not permitted to contact patients or receive requests from patients for medical advice or information on personal devices via phone, email, text messages, or any other form of technology. This is outside your scope of practice and considered in violation of this policy.
Central AT Guideline 2: Medical Record Storage & Security
The following standards and controls shall be implemented and maintained in all areas where medical records are located:
- All medical documents should be filed as soon as possible.
- When not in use, patient’s medical records shall be stored in either locked files or in a locked room.
- Access to keys to medical files and/or record room shall be limited to Central’s licensed athletic training staff.
Central AT Guideline 3: Access & Release of Medical Information
Confidentiality of all medical information shall be maintained in accordance with the Information Practices Act, the Confidentiality of Medical Information Act, and Central policy.
- Access to patient’s health care records is limited to persons needing the information for legitimate purposes
- Information that is shared should be limited to the minimum necessary, that is, the least amount of information necessary to accomplish the request
- Electronic and paper copies of personal health information (PHI) are protected and to accessed or transferred only to authorized individuals as regulate by HIPAA and or FERPA
- Information that is related to a patient’s health cannot be used unless authorized by the patient or someone acting on the their behalf and requires the patient to sign a “Release of Medical Information” form.
Central AT Guideline 4: Privacy
Centrl Athletic Training staff must understand that the main area of the athletic training facility may at times not provide the appropriate level of privacy for obtaining a detailed medical history; providing emergency care for an ill or injured patient; or for holding a private conversation with a patient, coach, or team physician.
- Therefore whenever deemed necessary a more private area of the facility should be utilized to protect the privacy needs and personal health information of the patient.
CENTRAL AT Guideline 5: Facility Security
Central athletic training staff members must remember to control access and maintain a secure facility at all times. Access to the facility is limited through the main hallway door for all athletic training students and patients. All doors must be locked when closing the facility.
- Keys and/or access cards to the facility shall be issued only to personnel approved by the head athletic trainer or designee.
- Access to the athletic training facility during the hours the facility is closed shall be limited to personnel authorized by head athletic trainer or designee.
- Non-athletic training facility staff members may be provided access to the facility only if a Central athletic training staff member is on duty.