Topic pick. Stephanie Orange

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DeVry University, New York *

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220

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Information Systems

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Feb 20, 2024

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docx

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I will create a training manual for HIPAA privacy and security rules. The manual will be targeted towards all healthcare organizational employees. The manual will cover the rules and regulations set forth by HIPAA regarding the privacy and security of patient health information. It will provide a detailed explanation of the different types of information that are covered under HIPAA, the rights of patients regarding their health information, and the responsibilities of healthcare employees to ensure that all patient information is protected and kept confidential. The manual will also provide guidelines on how to handle and dispose of sensitive information, how to report any breaches or violations of HIPAA rules, and how to ensure that all electronic health records are kept secure. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted to establish rules and regulations for the privacy and security of patient health information. All healthcare organizational employees are required to comply with these regulations to ensure that patient health information is protected and kept confidential. The purpose of this training manual is to provide a detailed explanation of the HIPAA privacy and security rules, the different types of information that are covered under HIPAA, the rights of patients regarding their health information, and the responsibilities of healthcare employees to ensure that all patient information is protected and kept confidential. The manual will also provide guidelines on how to handle and dispose of sensitive information, how to report any breaches or violations of HIPAA rules, and how to ensure that all electronic health records are kept secure. Chapter 1: Understanding HIPAA Privacy and Security Rules 1.1 HIPAA Privacy Rule The HIPAA Privacy Rule establishes national standards for the protection of certain health information. It provides patients with rights over their health information, including the right to access their information and the right to request that their information be corrected. 1.2 HIPAA Security Rule the HIPAA Security Rule establishes national standards for the security of electronic protected health information (ePHI). It requires healthcare organizations to implement technical, physical, and administrative safeguards to protect ePHI from unauthorized access, use, and disclosure. Chapter 2: Types of Information Covered by HIPAA 2.1 Protected Health Information (PHI) PHI is defined as any information that relates to the past, present, or future physical or mental health condition of an individual, the provision of healthcare to an individual, or the payment for the provision of healthcare to an individual. 2.2 Electronic Protected Health Information (ePHI) ePHI is any PHI that is transmitted or maintained electronically. Chapter 3: Patients' Rights 3.1 Access to Information Patients have the right to access their own health information. Healthcare organizations must provide patients with access to their information within 30 days of the request. 3.2 Right to Request Corrections Patients have the right to request that their health information be corrected if they believe it is inaccurate. Chapter 4: Employees' Responsibilities 4.1 Protecting Patient Information All healthcare organizational employees are responsible for protecting patient information. This includes ensuring that patient information is kept confidential, not sharing patient information with

unauthorized individuals, and reporting any suspected breaches or violations of HIPAA rules. 4.2 Handling and Disposing of Sensitive Information Healthcare organizational employees must follow guidelines for handling and disposing of sensitive information, including shredding paper documents containing patient information and securely deleting electronic files containing ePHI. Chapter 5: Reporting Breaches or Violations of HIPAA Rules 5.1 Reporting Requirements All healthcare organizational employees are required to report any suspected breaches or violations of HIPAA rules to their supervisor or the organization's designated HIPAA compliance officer. 5.2 Consequences of Non-Compliance Non-compliance with HIPAA rules can result in disciplinary action, including termination of employment, civil monetary penalties, and criminal charges. Chapter 6: Ensuring Electronic Health Records are Kept Secure 6.1 Technical Safeguards Healthcare organizations must implement technical safeguards to protect ePHI, including access controls, audit controls, and transmission security. 6.2 Physical Safeguards Healthcare organizations must implement physical safeguards to protect ePHI, including facility access controls, workstation use, and device and media controls. 6.3 Administrative Safeguards Healthcare organizations must implement administrative safeguards to protect ePHI, including security management processes, workforce security, and contingency planning. Conclusion: The HIPAA privacy and security rules are essential for protecting patient health information and ensuring that patient's rights are respected. All healthcare organizational employees must comply with these rules to prevent unauthorized access, use, and disclosure of patient information. By following the guidelines outlined in this training manual, healthcare organizational employees can help ensure that patient health information is protected and kept confidential. 1. Office for Civil Rights. (n.d.). Summary of the HIPAA Privacy Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html 2. Office for Civil Rights. (n.d.). Summary of the HIPAA Security Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html 3. Office for Civil Rights. (n.d.). Summary of the HIPAA Breach Notification Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html 4. U.S. Department of Health & Human Services. (2013, July 26). Summary of the HIPAA Privacy Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/laws- regulations/index.html 5. U.S. Department of Health & Human Services. (2013, July 26). Summary of the HIPAA Security Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html 6. U.S. Department of Health & Human Services. (2013, January 25). HIPAA Privacy Rule and Public Health. Retrieved from https://www.hhs.gov/hipaa/for-professionals/special- topics/public-health/index.html

7. U.S. Department of Health & Human Services. (2013, January 25). HIPAA Security Rule and Public Health. Retrieved from https://www.hhs.gov/hipaa/for-professionals/special- topics/public-health/index.html 8. U.S. Department of Health & Human Services. (2016, October 24). Breach Notification Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/breach- notification/index.html 9. U.S. Department of Health & Human Services. (n.d.). HIPAA Training Materials. Retrieved from https://www.hhs.gov/hipaa/for-professionals/training/index.html The training manual on HIPAA privacy and security rules can be used in conjunction with a risk management program in healthcare to help prevent and mitigate risks associated with the use and disclosure of patient health information. By training employees on HIPAA rules and regulations, healthcare organizations can reduce the likelihood of privacy breaches, data loss, and regulatory violations. In addition, the training manual can be used to help healthcare organizations develop policies and procedures that align with HIPAA rules and regulations. Items Covered in the Training Manual The training manual will cover the following items: 1. Understanding HIPAA Privacy and Security Rules - Overview of HIPAA Privacy and Security Rules - Protected Health Information (PHI) and Electronic Protected Health Information (ePHI) 2. Patients' Rights - Access to Information - Right to Request Corrections 3. Employees' Responsibilities - Protecting Patient Information - Handling and Disposing of Sensitive Information 4. Reporting Breaches or Violations of HIPAA Rules - Reporting Requirements - Consequences of Non- Compliance 5. Ensuring Electronic Health Records are Kept Secure - Technical Safeguards - Physical Safeguards - Administrative Safeguards By incorporating these items into a risk management program, healthcare organizations can help ensure that their employees are aware of their responsibilities and are equipped with the necessary knowledge and tools to protect patient health information. In addition, the manual can be used as a reference for employees to reinforce their knowledge and understanding of HIPAA rules and regulations. the objectives of the HIPAA Privacy and Security Rules Training Manual are to: 1. Provide an overview of the HIPAA Privacy and Security Rules and their importance in protecting patient health information. 2. Explain the different types of information covered by HIPAA, including Protected Health Information (PHI) and Electronic Protected Health Information (ePHI). 3. Outline patients' rights under HIPAA, including the right to access their information and the right to request corrections. 4. Detail employees' responsibilities for protecting patient information and handling and disposing of sensitive information. 5. Provide guidelines on how to report breaches or violations of HIPAA rules. 6. Explain the technical, physical, and administrative safeguards required to ensure that electronic health records are kept secure. 7. Reinforce the importance of compliance with HIPAA rules and regulations and the consequences of non-compliance. 8. Provide employees with the knowledge and tools they need to comply with HIPAA rules and regulations and protect patient health information. 9. Ensure that employees are aware of their role in preventing privacy breaches, data loss, and regulatory violations. 10. Help healthcare organizations develop policies and procedures that align with HIPAA rules and regulations. By achieving these objectives, healthcare organizations can help ensure that their employees are well-equipped to handle and protect patient health information and comply with HIPAA rules and regulations. The following training schedule is a sample that can be adapted to meet the needs of individual healthcare organizations: Module 1: Introduction to HIPAA Privacy and Security Rules - Overview of HIPAA Privacy and Security Rules - Protected Health Information (PHI) and Electronic Protected Health Information (ePHI) - Importance of HIPAA compliance Module 2: Types of Information Covered by HIPAA - Definition of PHI and ePHI - Examples of PHI and ePHI - Importance of safeguarding PHI and ePHI Module 3: Patients' Rights - Access to information - Right to request corrections - Importance of respecting patients' rights Module 4: Employees' Responsibilities - Protecting patient information - Handling and disposing of sensitive information - Importance of confidentiality and security Module 5: Reporting Breaches or Violations of HIPAA Rules - Reporting requirements - Consequences of non-compliance - Importance of reporting potential breaches or violations Module 6: Ensuring Electronic Health Records are Kept Secure - Technical safeguards - Physical safeguards - Administrative safeguards - Importance of keeping electronic health records secure Review and Assessment: - Review of key concepts - Assessment of knowledge and understanding of HIPAA Privacy and Security Rules The training schedule can be conducted over a period of time, such as one week or several weeks, depending on the availability of employees and the needs of the healthcare

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organization. The schedule can also be conducted in a variety of formats, such as in-person training sessions, online training modules, or a combination of both. By following a structured training schedule, healthcare organizations can ensure that all employees receive the necessary training to comply with HIPAA rules and regulations and protect patient health information.

Topic pick. Stephanie Orange

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