Are physicians and doctor's offices prohibited from maintaining patient medical charts at bedside or outside of exam rooms, or from engaging in other customary practices where the potential exists for patient information to be incidentally disclosed to others?


No. The HIPAA Privacy Rule does not prohibit covered entities from engaging in common and important health care practices; nor does it specify the specific measures that must be applied to protect an individual’s privacy while engaging in these practices. Covered entities must implement reasonable safeguards to protect an individual’s privacy. In addition, covered entities must reasonably restrict how much information is used and disclosed, where appropriate, as well as who within the entity has access to protected health information. Covered entities must evaluate what measures make sense in their environment and tailor their practices and safeguards to their particular circumstances.

For example, the Privacy Rule does not prohibit covered entities from engaging in the following practices, where reasonable precautions have been taken to protect an individual’s privacy:

  • Maintaining patient charts at bedside or outside of exam rooms, displaying patient names on the outside of patient charts, or displaying patient care signs (e.g., “high fall risk” or “diabetic diet”) at patient bedside or at the doors of hospital rooms.

    Possible safeguards may include: reasonably limiting access to these areas, ensuring that the area is supervised, escorting non-employees in the area, or placing patient charts in their holders with identifying information facing the wall or otherwise covered, rather than having health information about the patient visible to anyone who walks by.
  • Announcing patient names and other information over a facility’s public announcement system.

    Possible safeguards may include: limiting the information disclosed over the system, such as referring the patients to a reception desk where they can receive further instructions in a more confidential manner.
  • Use of X-ray lightboards or in-patient logs, such as whiteboards, at a nursing station.

    Possible safeguards may include: if the X-ray lightboard is in an area generally not accessible by the public, or if the nursing station whiteboard is not readily visible to the public, or any other safeguard which reasonably limits incidental disclosures to the general public.

The above examples of possible safeguards are not intended to be exclusive. Covered entities may engage in any practice that reasonably safeguards protected health information to limit incidental uses and disclosures.



Date Created: 12/19/2002
Last Updated: 03/14/2006

Content created by Office for Civil Rights (OCR)
Content last reviewed on July 26, 2013