Patient Rights (Revised 12-12-19)

PR 1.0 - Patient Confidentiality

Standard: The entity must have in place, policies and procedures which ensure the protection of patient confidentiality as defined by local, state and federal regulations.

Elements of Compliance:

• PR 1.1 The entity will collect and file signed confidentiality agreements from all staff that have access to patient data.

• PR 1.2 Each entity must have policies and procedures in place to ensure that the security and confidentiality of patient information is respected throughout the patient’s stay in the radiology facility. Patient information includes demographic information, clinical information, and medical images. Information may be in written or electronic form.

• PR 1.3 Each entity must have a compliance program in place as required under the Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH Act).

PR 2.0 - Physical Privacy

Standard: The entity must have in place, policies and procedures which ensure the privacy rights of patients.

Elements of Compliance:

• PR 2.1 Each entity must have policies and procedures in place to ensure that the patient’s physical privacy is respected throughout the patient’s stay in the radiology facility.

• PR 2.2 The physical environment includes the waiting room, changing room, examination room, post-procedure observation room, and counseling room.

PR 3.0 - Patient Complaint Process

Standard: The entity must have in place, policies and procedures for the collection and resolution of patient complaints.

Elements of Compliance:

• PR 3.1 All documentation regarding each serious complaint received by the facility must be maintained for at least 5 years from the date the complaint was received unless otherwise mandated by state or federal law or regulation.

• PR 3.2 The entity must post a notice that provides the consumer with adequate directions for filing serious complaints with the facility’s accreditation body if the facility is unable to resolve a serious complaint to the consumer’s satisfaction.

PR 4.0 - Informed Consent

Standard: The entity must obtain written, informed consent from each patient (or from patient’s authorized representative) for the provision of imaging services requiring such consent.

Elements of Compliance:

• PR 4.1 The entity must have policies and procedures in place for obtaining informed written consent.

• PR 4.2 The consent must include an explanation of risks, benefits, and alternatives for:

  • 4.2.1 high-risk procedures;

  • 4.2.2 procedures requiring sedation;

  • 4.2.3 participation in research projects;

  • 4.2.4 and/or otherwise defined by local, state, or federal law.

Revision History for this Article

Date

Section

Description of Revision(s)

12-12-19

All

Article created; FAQs incorporated; No criteria changes