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*The basic objectives of this chapter are to

  • Define the confidential physician-patient relationship grounded in ethical and legal precepts that strike a balance between patients' expectations of privacy and society's interest in the public health and safety.
  • Explain the sweeping federal regulations known by the acronym HIPAA (Health Insurance Portability and Accountability Act). State law governs the reporting obligations of physicians and nurses with broad divergence between states. There is no uniform national reporting statute. Medical directors and nurse managers should be alert to this potential source of confusion when a physician or nurse joins their department from another state.
  • Describe how emergency department (ED) leadership can provide their staff with accessible state-specific informational memoranda that summarize their respective states' reporting obligations.

*Disclaimer: This chapter is intended to provide information of a general nature only and is not intended to be construed as legal advice or serve as a substitute for competent legal counsel. The law is ever changing and the subject matter of this chapter continues to evolve according to competing policy considerations across state and federal jurisdictions, and information contained herein may have changed since publication.

The physician-patient relationship anticipates that candor in disclosing personal information of a private nature to one's physician is crucial to achieving an optimum therapeutic outcome. Since ancient times dating back, at least, to the 4th century bc era of Hippocrates, physicians have recognized an ethical obligation to guard the confidences of their patients. In the first textbook of medical ethics, written at the dawn of medicine's evolution into a modern scientific discipline, Dr Thomas Percival articulated the ethical imperative of physician-patient confidentiality as follows:

“In the large wards of an infirmary the patients should be interrogated concerning their complaints, in a tone of voice which cannot be overheard. Secrecy, also, when required by peculiar circumstances, should be strictly observed.”1

In some ways, modern EDs share features of Dr Percival's 18th century infirmary. Confidentiality concerns continue to be a challenge.2,3 While improvements in ED design have greatly improved patient privacy, patients still expect their caregivers to remain vigilant in protecting their privacy.


Historically, patients' medical records consisted of handwritten notes tucked safely away in physicians' offices. The emergence of the electronic health record (EHRs), by virtue of its broad accessibility and potential for unfettered distribution, engenders many privacy concerns. Confidential patient information today is vulnerable to exposure in ways never before contemplated by our forbearers in medicine. A single touch of a “send” button on a computer can transmit a patient's confidential health information to an unlimited number of recipients within seconds.

In response to fears that patients' confidential health information was vulnerable to compromise, the US Congress passed the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).4 HIPAA is a comprehensive law that ...

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