FAQ 370 Does the HIPAA Privacy Rule require that covered entities document all oral communications?
This is guidance related to the requirement that covered entities document oral communications under the HIPAA Privacy Rule
Final
Issued by: Office for Civil Rights (OCR)
Does the HIPAA Privacy Rule require that covered entities document all oral communications?
Answer:
No. The Privacy Rule does not require covered entities to document any information, including oral information, that is used or disclosed for treatment, payment or health care operations.
The Rule includes, however, documentation requirements for some information disclosures for other purposes. For example, some disclosures must be documented in order to meet the standard for providing a disclosure history to an individual upon request. Where a documentation requirement exists in the Rule, it applies to all relevant communications, whether in oral or some other form. For example, if a covered physician discloses information about a case of tuberculosis to a public health authority as permitted by the Rule at 45 CFR 164.512, then he or she must maintain a record of that disclosure regardless of whether the disclosure was made orally, by phone, or in writing.
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