MIRAMONT BEHAVIORAL HEALTH POLICY AND PROCEDURE MANUAL

DEPARTMENT: Rights of PatientsSUBJECT: Patient Privacy
POLICY AND PROCEDURE: 1800.26Page 1 of 2
REFERENCES: JC, CMS, Wisconsin DHS 94
EFFECTIVE DATE: July 1, 2021APPROVED BY: Quality/PI Council/ Governing Board

PURPOSE:

To safeguard privacy of each and every patient.

POLICY:

It shall be the policy of Miramont Behavioral Health every effort be made to protect
each patient’s right to confidentiality and privacy. Hospital, contract, and medical
staff shall follow the procedures, as delineated below:

PROCEDURE:

A. Visitors to areas being utilized by patients will be minimized. Patients who
are on unit or areas to be toured will be forewarned of guests’ arrival and
given opportunity to close doors or exit area being toured temporarily.
Staff should be asked prior to arriving on unit.
B. Patient names are not posted on bulletin board in public areas of hospital.
C. Do not confirm admission of patient to hospital to persons not authorized
to have that information. Per the direction of the Governing Board:
Unauthorized callers (by phone) or visitors who ask to speak to a patient,
shall be standardly told, “I am sorry, but state and federal privacy laws will
not allow me to confirm or deny the presence of a patient in this hospital.”
D. Always knock on patient’s door before entering.
E. Always inform the patient of searches.
F. Keep noise level to minimum to avoid disturbing other patients on unit.
G. Patients are not allowed to tape or photograph activities or patients.
H. The Hospital staff are not allowed to tape or photograph the patient except
as allowed under s.51.61 (1) (o), Stats and Wisconsin DHS 94.
I. Staff shall not identify patients by name when using paging systems,
either local or long distance.
J. In general, make every effort to communicate to each patient, your respect
for him/her as a person.
K. Never discuss patients or events from Miramont Behavioral Health
with any person not authorized to acquire patient information.

L. Never discuss patients in open and public areas. Such conversations
shall be conducted in private areas and only with staff who have a “need
to know”.