Resource Centre - Confidential and Sealed Patient Records
Some Hospital Information Systems (HIS), Home and Community Care Services (HCCS), and Ontario Laboratory Information Systems (OLIS), will flag a patient’s record or certain aspects of the patient’s account (such as reports or visits) as confidential or sealed.
The following table explains how confidential and sealed patient records are displayed in ClinicalConnect based on the source of the record.
Confidential/Sealed Record Source
|ClinicalConnect Display Details|
ClinicalConnect will display the confidential and sealed flags that have been applied in the source hospital systems to the following confidential/sealed record levels (if applicable):
Confidential and sealed Home and Community Care Services patient records are not made available in ClinicalConnect and will not display.
ClinicalConnect will recognize OLIS confidential and sealed reports, prevent the user from viewing the information, and present a patient consent directive message.
OLIS can restrict data for a specific test or the entire OLIS record. If an OLIS test is restricted, that test will not appear in the associated ClinicalConnect module. A message will be displayed indicating Some or all information has been restricted due to a patient consent directive.
If the entire OLIS patient record is restricted, then no OLIS data will be displayed in any module of ClinicalConnect and the same message will be displayed indicating Some or all information has been restricted due to a patient consent directive. OLIS restricted records cannot be overridden in ClinicalConnect.
How do HIS confidential/sealed records display in ClinicalConnect?
Confidential/Sealed Search Results View
When performing a Simple or Advanced Search, confidential and sealed patient records display in the search results with only the following patient information is available:
- Full Name
The remaining fields are masked as confidential or sealed. This limited demographic information is displayed to assist the physicians and clinicians in accurately identifying a patient’s record.
Confidential Result Example:
Sealed Result Example:
Station Census View
When viewing a station census, a confidential/sealed patient record will display in the station census list with only the following patient identifies visible: Medical Record Number (MRN), Full Name and Gender
If a confidential/sealed patient has been added to your worklist, the record will display the confidential/sealed mask each time you log into a ClinicalConnect session. A confidential/sealed override can be performed (by physicians only) to view the patient’s record. If an override is not performed, the patient will display in your worklist with only the following patient identifies visible: Medical Record Number (MRN), Full Name, Gender and Facility
Confidential/Sealed Encounters flagged in the Visits Module
When a patient’s specific encounter or visit has been sealed by the source system, the patient demographic details will display in the patient header for all visits except those with confidential/sealed restrictions if selected.
If a confidential/sealed encounter is selected from the visits module, physician users will be prompted with the confidential/sealed override reason message. If you do not wish to proceed with the override, simply click the Cancel button.
All other users will not be permitted to perform the override and will receive the following message This record has been sealed by the patient. Only a physician can override this seal.
Confidential Tests and Reports
In some instances a specific laboratory test or report can be confidential. Confidential test results and reports mask all information except the Facility.
Confidential Override Privileges
Only physicians have been assigned override privileges where they are able to override the confidential or sealed restriction and access the record. Non-physician users will not have override privileges and will be presented with a confidential/sealed data mask screen when accessing a patient’s confidential or sealed record, specific encounter, or a specific test or result.
Physicians accessing a confidential or sealed patient record will be presented with the confidential/sealed override reason message and must select the most appropriate override reason.
If you do not wish to proceed with the override, click the Cancel button.
All overrides are logged, monitored, and audited.