OBSERVER PACKET CHECK LIST

ITEMS TO BE SUBMITTED

OBSERVER APPLICANTS:

Using the checklist, send completed pages listed below to the Division Coordinator

Dear Observer Applicant,

The Office of Academic Affairs has reorganized to centralize the processing of all student observers, in doing so; we will be reducing the various applications to only one. This process is also an important tool for us to track observers and to assure all applicants have an equal opportunity to observe. To facilitate the processing and tracking of all student observers please complete materials provided in this packet, when the packet is complete please forward to the division coordinator/administrative assistant.

 / PAGE / SUBMIT TO THE DIVISION COORDINATOR/ADMINISTRATIVE ASSISTANT
2 / Observer Request (coordinator/division will obtain CHLA ID #)
3 / Application for Observation/Job Shadowing (coordinator/division will obtain CHLA ID #)
Refer to page 4 / Documentation of Immunizations (Obtain from your physician or school)
5 / Addendum C – Observer Status (Signed & Dated)
6 / Addendum D – Confidentiality Stated (Signed & Dated)
9 10 / Completed HIPAA Competency Test (Signed & Dated)
12 / Addendum F – Environment of Care Observation/Job Shadowing (Signed & Dated)

Feel free to contact us if you have any questions:

Raquel Landeros (323) 361-2127

Martha Bustamante (323) 361-4541

NOTE:

Please allow 7-10 days for processing, our office will notify the division of clearance by email.

The CHLA picture ID cards are property of CHLA and must be returned on the final day of the rotation to Raquel Landeros or Martha Bustamante, Duque Bldg., Door 1-294.

Academic Affairs, Undergraduate Medical Education, Door # 1-294, – MS #71 – Ext. 12127 or 14541

Entire packet must be completed/scanned and emailed directly to Academic Affairs / Undergraduate Medical Education; Raquel Landeros Martha Bustamante: . Student may not start until the application and all supporting documents are received and are cleared by our office. Due to high demand of observer experiencesOBSERVERS MAY ONLY APPLY FORONE OBSERVER EXPERIENCE.

OBSERVER REQUEST
Medical Student / Visiting Student / Dental Student /Research Observer/ UCEDD/ RSP/PIT
(High School Student are not eligible)
Name of Observer:
First Name – Middle Name – Last Name / SS#: / CHLA ID#
Institution/School:
Name, City, State / Are you an Undergraduate
medical student?
 Yes  No / School: Year level
Please check appropriate Applying Status:
 Medical Student Observer
2 weeks maximum /  Visiting Undergraduate
StudentObserver
1 week maximum / Dental Student Observer
1 week maximum /  Other (Specify)
2 weeks maximum
Start Date: / Start Date: / Start Date: / Start Date:
End Date: / End Date: / End Date: / End Date:
 Research Observer /  USC Student Required
ScholarlyProgram (RSP) /  UCEDD /  Physician in Training (PIT)
Observer-No Patient Contact
CCI #:
HIM #:
Start Date:1/14/13 / Start Date: / Start Date: / Start Date:
End Date:5/15/13 / End Date: / End Date: / End Date:
Division Approval:
Name of Division:
Emergency Medicine / Attending Supervising Student:
First Name - Last Name
Danica Liberman / Supervising Attending Contact Info:
Phone: 323-361-2109
Pager:
Email:
Division Coordinator:
Vincent Wang / Email:
/ Phone #:
323-361-2109
CHLA Dept./Division Head or Designee Name
Name:______ Please check:  Division Head  Designee
Signature:X______Date:______
  • Coordinators must email a PeopleSoft Application to ; once the CHLA ID # is obtain it must be included on the Request Form & Application
  • Research Observers who need KIDS access Coordinators must submit a RFUA to the HELP DESK and include CCI #
  • HIM: No medical records or KIDS access privileges for Observers
  • During influenza season (October-April) all students must provide documentation of influenza vaccine, if documentation is not submitted an early termination date will result until documentation is received.

ADDENDUM A

APPLICATION FOR OBSERVATION/JOB SHADOWING

PLEASE TYPE or PRINT LEGIBLY

PARTICIPANT INFORMATION
Social Security #: / CHLA ID# / LAST NAME: / FIRST NAME / MIDDLE
STREET ADDRESS: / CITY/STATE: / ZIP CODE:
BIRTHDATE: / E-MAIL ADDRESS: / HOME or CELL PHONE:
NAME OF SCHOOL/CITY/STATE: / GRADE LEVEL AT PRESENT:
HAVE YOU EVER BEEN CONVICTED OF A FELONY: / IF YES, PLEASE DESCRIBE:
NAME OF EMERGENCY CONTACT: / RELATIONSHIP: / HOME PHONE: / CELL PHONE:
REFERRED BY:
Danica Liberman / IS THIS PERSON A CHLA EMPLOYEE:
Yes. / IF SO, WHAT DEPT:
Emergency Medicine
OBSERVATION/JOB SHADOWING REQUEST
REFER TO OBSERVER REQUEST FOR ALLOWABLE NUMBER OF WEEKS
NO GRADE OR CERTIFICATE IS ISSUED FOR AN OBSERVER/SHADOW EXPERIENCE
DATE/S REQUESTED:
FROM: JANUARY 14, 2013 TO: MAY 15, 2013 / START TIME REQUESTED:
N/A / END TIME REQUESTED:
N/A
UNIT/AREA OF INTEREST REQUESTED:
Emergency Medicine / REASON FOR YOUR REQUEST:
USC Minor in Health Care Studies Program – MEDS-490 Course
PARTICIPANT AGREEMENT
As an observer/job shadower at Children’s Hospital Los Angeles I agree:
  • To hold as absolutely confidential all information which I may obtain directly or indirectly concerning patients, parents, doctors, or personnel, and will not seek confidential information in regard to a patient.
I certify that the information contained in this application is true and complete to the best of my knowledge. I realize this information is confidential and may be used to determine my eligibility as an observer/job shadower at CHLA. If accepted, I agree to be prompt and dependable, honest and cooperative, accept supervision and constructive criticism gracefully, maintain a high standard of conduct, and observe all hospital rules, policies and procedures. I understand that my observation/job shadower status can be terminated at any time for failure to comply with the policies, rules, and regulations of the Hospital; absences without prior notification, unsatisfactory attitude, work or appearance; or any other circumstances which, in the judgment of the Hospital would make my continued service as an observer/job shadower contrary to the best interests of the Hospital.
ANY PERSON WHO INTENTIONALLY GIVES MISLEADING OR FALSE INFORMATION WILL BE SUBJECT TO IMMEDIATE TERMINATION.

Print Name:

Signature: ______
Date:

ADDENDUM B

Clearance Process For

All Fellows, Rotating Residents, Students, Observers, etc…

(Hereafter Referred to As “Trainees”)

In order to facilitate the processing of all trainees the following must be noted:

All trainees must be cleared by the Academic Affairs Office and Employee Health Services (EHS) before the Safety & Security/Parking Office will issue a CHLA identification badge and parking card.

The following are the “CHLA Health Screening/Clearance Requirements” from Employee Health Services.

Every interim employee, student, intern, rotation resident, fellow, volunteer or persons coming to observe a procedure must be cleared by the Employee Health Services prior to starting their employment, training rotation, or observation period at CHLA. The following documents must be provided to the EHS nurse at the time clearance is being requested.

Please provide a copy of your documented immunization record containing:

  1. Written document of two measles, mumps, rubella (MMR) vaccinations as a child in persons born after 1950, or one MMR after the age of seventeen (17)

Or

Serologic (antibody titers) evidence of immunity to measles and rubella (German Measles).

  1. Serologic evidence of immunity to chicken pox (varicella) or verbal knowledge of having the disease.
  2. Written documentation and report of TB skin test (Mantoux) or T-Spot / Quantiferon TB Test within the previous twelve months

Or

In skin test positive persons, a written report of chest x-ray results taken within the previous year.

Or

4. Written documentation of recent influenza vaccination (required during flu season during the months of October – April)

Parking cards and identification will not be issued without an EHS clearance. If the above is not carried out, the trainee will be considered unauthorized to begin training at CHLA and is not permitted to be on campus.

ADDENDUM C

Academic Affairs – MS #71

Ext. 12127 or 14541

Observer Status

I understand that my role as a visiting/shadowing student / undergraduate student/ Research Observer/ Required Scholarly Program Student (RSP), USC UCEDD , Physician in Training (PIT) does not allow me to obtain a patient’s history, act as a translator, examine patients, or interact with any patient being seen at CHLA or at any other sites affiliated with or contracted by CHLA. As many staff and faculty members, residents, etc., may not be aware of my status, I will explain my role whenever asked to interact with a patient. If I feel that undue pressure is being applied, I will report the situation to the Chief of Medical Staff at CHLA. I will honor privacy and not remove or share any confidential patient information.

I also understand no grade or certificate of completion will be issued for this experience.

X______X______

Signature – ObserverSignature–Witness (Supervising Physician)

______

Print-Observer’s Name (first-middle-last)Print-Witness’ Name (Supervising Physician)

______

DateDate

ADDENDUM D

CONFIDENTIALITY STATEMENT

In order to protect the confidentiality of patient care and hospital matters, Children’s Hospital Los Angeles considers all information regarding its patients, their families, hospital employees and hospital business as confidential. All board members, officers, employees, volunteers, residents/fellows, students, Medical Staff members or practitioners with temporary privileges are required to adhere to this policy and not release or disclose any information without appropriate written authorization. The hospital complies with all applicable federal (HIPAA) and state law regarding the release of protected health information.

This policy includes the confidentiality of medical staff records and procedures, all patient information, employee personnel files and information contained in the hospital computer systems.

Board members, officers, employees, volunteers, residents/fellows, students, Medical Staff members or practitioners with temporary privileges are also asked to refrain from discussing any patient information or hospital business in public areas, including corridors, elevators, the cafeteria, McDonalds, hospital lobbies or waiting rooms.

ACKNOWLEDGEMENT:

I______, have read and agree to

PRINT NAME

comply with the Children’s Hospital Los Angeles, Confidentiality Policy. I understand that I am prohibited from divulging any information regarding patients, their families, employees or matters related to hospital business except as mandated by hospital policy and/or law.

SignatureX______Date______

ADDENDUM E

HIPAA

(Health Insurance Portability and Accountability Act)

OBSERVATION/JOB SHADOWING

Primary Goals of the HIPAA Legislation

  • Assure health insurance portability
  • Reduce healthcare fraud and abuse
  • Simplify electronic administrative processes
  • Guarantee security and privacy of health information

HIPAA is the most sweeping legislation to affect healthcare since Medicare in 1965. Nearly everyone will be affected: payors, employers, providers, clearinghouses, practice management system vendors, billing agents, and service organizations. In regard to protecting patient information, security is defined as the protection of information, data and systems from accidental or intentional access by unauthorized users. Common threats to patient information security include talking about patients, using identifiable information such as names, diagnosis, etc, in public areas.

Examples of Protected Health Information

  • Clinical information
  • Name and social security numbers
  • Names of relatives, family name, and employer
  • Health plan numbers and account numbers
  • Telephone numbers, fax numbers and emails
  • All dates related to the individual, i.e., birth, etc
  • Geographic subdivision smaller than state
  • Any information that can reasonably identify a patient

Penalties for Non-compliance with HIPAA Regulations

Monetary Penalty /

A.Term of Imprisonment

/

B.Offense

$100 / N/A / Single violation of a provision.
Up to $25000 / N/A / Multiple violations of an identical requirement for prohibition made during a calendar year.
Up to $50000 / Up to 1 year / Wrongful disclosure of individually identifiable health information.
Up to $100000 / Up to 5 years / Wrongful disclosure of individually identifiable health information committed under false pretenses.
Up to $250000 / Up to 10 years / Wrongful disclosure of individually identifiable health information committed under false pretenses with intent to sell, transfer, or use for commercial advantage, personal gain, or malicious harm.

Failure to implement transaction sets can result in fines of $225000 per year or more.

($25,000 per requirement, times nine transactions)

Failure to implement privacy and security measures can result in imprisonment.

Patient’s Rights

  • Patients have the right to

-Look at and obtain a copy of their health information.

-Know how their health information has been used and to whom it has been disclosed.

-File a formal complaint if their privacy has been violated.

-Patient or parental consent must be obtained before a patient’s health information can be released to family members.

-Protecting patient information includes electronic, written and verbal communication.

Notice of Privacy Practices

Covered Entities must provide a simple explanation of their privacy practices. Direct treatment providers must make a good faith effort to obtain written acknowledgment of receipt of the notice of privacy practices.

Minimum Necessary

Employees should use only the information minimally necessary to do their job.

Business Associates

Covered Entities may disclose PHI to business associates. They are required to have contracts that require their business associates to observe certain privacy standards listed in the regulations.

Personal Representatives (Parents)

  • HIPAA gives control of a minor’s PHI to the parent, guardian, or person acting in loco parentis with certain exceptions.
  • HIPAA does not overturn state laws that give providers discretion to disclose PHI to parents or prohibit the discloser of PHI to a parent.
  • Verification of the personal representative’s identity is a critical overlap with physical security.

PRIVACY DO’S

  • Immediately remove all patient health information from printers, fax machines and photocopiers.
  • Dispose of protected health information in the appropriate confidential bin.
  • When conducting a conversation regarding a patient, do so in a private place or speak quietly so you can’t be overheard.
  • Keep medical records and other documents containing personal health information out of public view.
  • When possible, close patient/examining room doors or draw curtains and speak softly when discussing patient’s health information.
  • Treat other people’s confidential information as if it were your own.
  • Password protect your laptop computer and your personal digital assistant.
  • Report privacy violations in the hospital to the Privacy Officer, at extension 2302 so we can improve our organization’s privacy practices.

PRIVACY DON’TS

  • Don’t share confidential patient information with anyone who doesn’t need to know in order to do his or her job.
  • Don’t share passwords on your computer.
  • Never access information about a patient unless you need it to do your job.
  • Don’t walk away from open medical records, lab results, or computers, etc. Close records first and use a bookmark, if necessary.

HIPAA Competency Test

OBSERVATION/JOB SHADOWING

Please circle correct answer:

  1. Which of the following statements about confidentiality and protecting patient information are true?
  1. Only authorized people are allowed to look at or use patient information
  2. Any health information that can identify a person must be treated as confidential
  3. Confidential information should be shared only with those who have the “need to know”
  4. All of the above
  1. In regards to protecting patient information, security is defined as:
  2. The requirement that all patient information either be under lock and key or protected by security officers
  3. The protection of information, data and systems from accidental or intentional access by unauthorized user
  4. None of the above
  5. All of the above
  1. Which of the following standards require health care organizations to protect patient information?
  2. Chain of Trust (COT)
  3. Prospective Payment System
  4. Health Insurance Portability and Accountability Act (HIPAA)
  5. Outcomes Assessment Information Set (OASIS)
  1. Organizations that violate patient privacy and security standards can suffer penalties such as:
  2. Fines, possibly in the thousands of dollars
  3. Imprisonment
  4. Bad public relations
  5. All of the above
  1. Common threats to patient information security include:
  2. Talking about patients, using identifiable information such as names, diagnosis, etc, in public areas
  3. Not logging off the computer when finished
  4. Maintaining patient listings and other information in full view of unauthorized people
  5. All of the above
  1. Patients have the right to:
  2. Look at and obtain a copy of their health information
  3. Know how their health information has been used and to whom it has been disclosed
  4. File a formal complaint if their privacy has been violated
  5. All of the above
  1. Protected health information (PHI) is any information that can identify a patient
  2. True
  3. False
  1. Talking about a patient’s condition or diagnosis, while in a public area, would be a violation of patient privacy even if the patient’s name were not mentioned.
  2. True
  3. False
  1. Patient or parental consent must be obtained before a patient’s health information can be released to family members
  2. True
  3. False
  1. Protecting patient information includes all forms of communication—electronic, written and verbal.
  2. True
  3. False

Print Name:

Signature:

Date:

ADDENDUM F

ENVIRONMENT of CARE

OBSERVATION/JOB SHADOWING

Please keep this information, and sign and return the enclosed statement indicating that you have read and understand your role in the safety, security, and environment of care at Children’s Hospital Los Angeles. Codes (Overhead Page) (Ext. 33)

  • Code Blue - Medical Team Emergency
  • Code Green - Hazardous Spill
  • Code Yellow - Trauma Team
  • Code Red – Fire
  • Code Orange - Disaster
  • Code 10 – Missing Patient
  • Code 12 – Bomb Threat
  • Code 13 – Community Disturbance
  • Code 99 – Hospital Lockdown
  • Dr./Mr. Strong – Violent Behavior (Ext. 711)
  • Dr./Mr. Adam Strong – Armed Individual (Ext. 711)

Identification Badges

  • Your CHLA ID badge must be worn at
all times when on the CHLA premises
  • Your ID badge must be worn on the upper
body with the photo and name facing outward
  • If you loose your ID, you must report it
missing to Security (Ext. 2313) and the
Parking Office (Ext. 2214)

Visitor Badges