Page 408 - eBook Version 8 Book 1 of 2 JUL 2022

HIPAA Worksheet
Standard/ Policy/ Gudance
Location
Present in Chart (Circle ONLY one)
Notes
Applicable to this visit?
YES
NO
Is this a re-consent?
YES
NO
Research HIPAA Form Stamped with IRB approval
IRB
Actual Document
YES
NO
Current HIPAA form used (signature date is after form approval date)
IRB
Actual Document
YES
NO
If HIPAA Authorization is in the Medical Record, there is NO mention of DNA
Children's Policy
EPIC
YES
NO
N/A
Name of Research Participant completed
Join Commission
Actual Document
YES
NO
Signature of Research Participant if applicable (> 18 years of age)
Join Commission
Actual Document
YES
NO
N/A
Printed name of Legal Representative (if applicable)
Join Commission
Actual Document
YES
NO
Relationship to Research Participant completed
Join Commission
Actual Document
YES
NO
Identification of Legal Representative (e.g. parent, legal guardian...)
Join Commission
Actual Document
YES
NO
Signature of Legal Representative with Date and Time
Join Commission
Actual Document
YES
NO
Auditor Initials________________________________
MR#__________________________
Date____________________________
FOR AUDIT PURPOSES ONLY