Instructions for Completing Required Documentation for Clinical Rotations Welcome to The Hospitals of Providence. An active Affiliation Agreement is required in order to complete any clinical rotations in the network. In an effort to ensure we provide a positive learning experience and ensure the safety of our patients, employees, & students, the following are required, in their entirety, to be submitted a minimum of two weeks from the clinical start date: Faculty/Instructor Credentialing form of individual overseeing the students Course Syllabus/Objectives Skills Checklist Clinical Site Request Form Pre-Clinical Clearance form to include the Faculty/Instructor (Separate Link) Car License Plate form Request to access Clinical Applications (limited to last semester nursing students only). Contact facility to schedule training. Read the following information sheets: Student Orientation Sheet and Emergency Codes (each facility has a specific link). Print the last page titled Orientation Checklist. Date and initial each box where appropriate, then print your name in the blank space provided and sign at the bottom. This is required for both students and Faculty/Instructor. View HIPAA Tenet: Information & Privacy Security Training Video. This is required for both students and Faculty/Instructor. Faculty/Clinical Instructor to request answer key from facility contact person. Complete posttest, grade, & submit with packet. http://mm1.tenethealth.com/etenet/tenethealth/tenethipaasec2005.wmv Facility Specific & Statement of Responsibility forms are to be completed on first day of clinical.
Contact information: Rachel Goodman-Onopa, RN, MSN Point of contact for all nursing clinical requests Joint Faculty/ Nurse Clinician Providence Memorial Hospital 915-577-7489 Rachel.Goodman-Onopa@Tenethealth.com Sandy Novo Clinical Education Coordinator Providence Memorial Hospital 915-577-6021 Sandra.Novo@Tenethealth.com Point of contact for all non-nursing clinical requests Rebecca Castruita, MSN, RN Point of contact for all nursing clinical requests Nurse Educator Sierra Providence East Medical Center 915-832-2151 Rebecca.Castruita@Tenethealth.com Brian Dinsdale, CRT Point of contact for all non-nursing clinical requests Clinical Educator Sierra Providence Eastside Medical Center 915-832-2152 Brian.Dinsdale@Tenethealth.com Sandra Rivera, MSN, RN Point of contact for all nursing and non-nursing clinical requests RN Residency Manager/Clinical Educator Sierra Medical Center 915-747-2674 Sandra3.Rivera@Tenethealth.com Terry Moreland, MSN, RN Administrative Director Education Services Providence Memorial Hospital / Sierra Medical Center 915-747-2002 Terry.Moreland@Tenethealth.com
FACULTY/INSTRUCTOR CREDENTIALING FORM This form is to be completed and submitted with the Pre-Clinical Clearance Form in compliance with JC requirements every semester. Directions: Please print or type the requested information into the spaces provided. Faculty/Instructor s Name: Home: Cell: Email address: Office: Beeper: ID Number: Emergency Contact: Contact Number: Credentials: License #/State/Expiration Date: Organization/School: Primary Source: Verified: CPR Status: Verified: Title/Position: Date of Employment: Briefly describe the qualifications/experience(s) that qualify this person as being competent to serve as a clinical rotation instructor: (Attach Copy of the Pre-Clinical Clearance Form) I hereby verify that the above information is current and accurate: Faculty/Instructor Signature: Date: Immediate Supervisor s Signature: Date: License & CPR status verified by: Date: Initials:
Clinical Site Request Form Date Request Initiated: Name of Requester: Contact Number: Clinical Experience: Name & Address of School: Description/Number of Student(s): Department desired for clinical: Dates of clinical: Days of the week: Dates: Times of clinical: Affiliation Agreement is current? Yes No Action being taken to: Comments:
Student Clinical Rotation License Plate Log Name (Print) 1. Car Model Car Make Year Color License Plate Number School Instructor Clinical Dates Shift 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
The Hospitals of Providence Required Data for Student Access to Electronic Documentation Name Birth Month/Day Student ID Email Address Phone Number
INFORMATION PRIVACY & SECURITY AND HIPAA TRAINING ROSTER The training media included: Tenet: Information Privacy & Security and HIPAA Training Video School Name: Faculty/Clinical Instructor Name: Course/Program Name: My signature is acknowledgment that I have viewed the Tenet: Information Privacy & Security and HIPAA Training Video and completed/passed the post test. Date Printed Name Name of School Title Student (S) Instructor (I) Signature Test Score Passing score is 80%. Reviewed/Revised: 12/2010
INFORMATION PRIVACY & SECURITY TEST QUESTIONS PRIVACY & SECURITY POLICIES AND PROCEDURES, HIPAA AND SARBANES-OXLEY (SOX) 1. Under the HIPAA privacy rule, it is illegal to: Obtain information from a patient during treatment Share information obtained from a patient with the patient s physician Fail to adequately protect health information from release 2. Tenet has policies that provide guidance for: Sanctions and mitigation Training requirements Neither of these answers Both of these answers 3. Tenet has policies and procedures that outline directives for maintaining the privacy of Protected Health Information (PHI). 4. Patient privacy means: Patients have a right to expect their health information will be protected Employees are no longer required to protect patient information Patients must take steps to protect their health information 5. Improper disclosure of PHI can result in a criminal penalty of up to $250,000 or 10 years of prison. 6. Individuals working in healthcare can share information they overhear while at work if: The patient is a famous person The individual s job requires them to share the information The patient is a member of the individual s family The patient is the individual s friend 7. Tenet has policies to address: A patient s right to amend his or her Protected Health Information (PHI) A patient s right to restrict access to his or her Protected Health Information (PHI) Both of these answers Neither of these answers 8. Privacy protections cover a patient s health information, such as reason for treatment, the patient s name, address, social security number, and telephone number. 9. Healthcare operations are defined in the HIPAA privacy rules and are indirectly related to the treatment of a patient or payment for healthcare services. Information Privacy & Security Test Questions and Acknowledgement Page 1 of 3
10. Who is responsible for maintaining the privacy of Protected Health Information (PHI)? The patient Any member of the patient s family Every employee and member of the workforce 11. If you suspect that someone is not following the Privacy Policies and Procedures, you should report this to your supervisor, local Compliance Officer or local Privacy Officer. 12. You can protect the confidentiality of patient information by: Making sure that your access IDs and passwords are not shared with others Making sure medical records are not left on the top of nursing station counters accessible to the public Making sure you do not access information that is not necessary for you to perform your job All of these answers are true 13. No matter what department you work in, you have a responsibility for assisting in protecting a patient s confidential information. 14. What is the Notice of Privacy Practices (NPP)? A notice that is supplied to computer repair services to explain what file formats are used in the healthcare organization A notice included only in patient billing forms A notice required by HIPAA that tells all patients how their Protected Health Information (PHI) will be used and disclosed 15. Confidential information includes: Patient information Payroll information Trade secrets All of the above 16. Malicious software is any kind of software or code that could cause harm to an information system and includes viruses. 17. A fax containing confidential patient information is sent to a residence in error. This should be reported as an incident. 18. It is Christmas time and you want to stop by Lots for Tots on your way home to pick-up a toy for a neighbor s child. You will be taking work home and that includes documents containing confidential information. Which of the following is the best method for securing that information? Put the files in a locked briefcase Put the briefcase in your trunk before going into the store Drop off your briefcase at home before going to the store Put the files in a folder and leave them on the front seat of your car 19. Company policy requires that software audits be performed once per year. Information Privacy & Security Test Questions and Acknowledgement Page 2 of 3
20. You received an e-mail with an attachment called FunnyFotos.exe from an unknown party. You should: Open the attachment and enjoy the funny photos Forward this e-mail to all of your friends Forward the e-mail to everyone you work with Delete the e-mail without opening it 21. You have 10 different passwords and have a hard time remembering them all so you have written them down. The best place to store this information is: Under P in your rolodex Under your keyboard Thumb tacked next to your computer None of the above 22. Your UserID is Abcdef01 and your password is Abcdef01. This is considered a strong password. 23. When faxing information, the fax must include a cover sheet that contains a confidentiality statement? 24. The Information Security Policies and Procedures identify three types of information classifications. Those classifications include: Confidential Information Proprietary Information Public Information All of the above As of April 14, 2003, the federal Health Insurance Portability and Accountability Act (HIPAA) provides patient protections in connection with the use and disclosure of their health information, in addition to those protections that already exist under state law. Tenet Healthcare Corporation is committed to protecting the privacy and security of our patients health information. If you have questions about the information presented in the Information Privacy and Security video or the Information Privacy and Security policies and procedures please contact Tenet Healthcare s Privacy and Security Office at (469) 893-2009 or your local Hospital Compliance Officer. Please provide the information below and return the sign and dated form to your Hospital Educator or the Hospital Compliance Officer. I certify that I have reviewed the Information Privacy and Security training video. I understand that I will be accountable for the information contained therein. Should I choose to reveal confidential patient information to anyone, I acknowledge that the Hospital provided me with the applicable information and training in order to prevent any and all violations of the laws regarding patient privacy, security and confidentiality. I also understand that this acknowledgement will be maintained as a record of my participation in the HIPAA training program and may be reviewed by the Federal Government. Signature of Individual Date Printed Name: Address: City/State/Zip: Phone: ( ) Information Privacy & Security Test Questions and Acknowledgement Page 3 of 3