Documenting conversations

December 5, 2003

Does the HIPAA privacy rule require that I document all oral communications with patients?

Q: Does the HIPAA privacy rule require that I document all oral communications with patients?

A: No. But the rule does require that you keep records of certain discussions. For example, if you tell a public health authority about a patient's communicable disease or a law-enforcement official about a suspected victim of a crime, you must maintain a written record of that conversation.

There are non-HIPAA-related reasons to document oral communications, as well. Let's say you've instructed a patient to take a particular medicine or to avoid a certain behavior. If the patient proves noncompliant, you'd be wise to have a record of that. Indeed, a paper trail that clearly supports your original advice would make any future defense against medical malpractice easier.