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A hospital customarily displays patients' names next to the door of the hospital rooms that they occupy. Will the HIPAA Privacy Rule allow the hospital to continue this practice?


The Privacy Rule explicitly permits certain incidental disclosures that occur as a by-product of an otherwise permitted disclosure—for example, the disclosure to other patients in a waiting room of the identity of the person whose name is called. In this case, disclosure of patient names by posting on the wall is permitted by the Privacy Rule, if the use or disclosure is for treatment (for example, to ensure that patient care is provided to the correct individual) or health care operations purposes (for example, as a service for patients and their families). The disclosure of such information to other persons (such as other visitors) that will likely also occur due to the posting is an incidental disclosure.

Incidental disclosures are permitted only to the extent that the covered entity has applied reasonable and appropriate safeguards and implemented the minimum necessary standard, where appropriate. See 45 CFR 164.502(a)(1)(iii) (PDF - 3 pages). In this case, it would appear that the disclosure of names is the minimum necessary for the purposes of the permitted uses or disclosures described above, and there do not appear to be additional safeguards that would be reasonable to take in these circumstances. However, each covered entity must evaluate what measures are reasonable and appropriate in its environment. Covered entities may tailor measures to their particular circumstances.



Date Created: 12/19/2002

Last Updated: 03/14/2006