Section: Medical Staff Office Page: 1 of 2

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1 Section: Medical Staff Office Page: 1 of 2 Subject: Job Shadowers and Observers Not Covered Under Clinical Affiliation Agreement Executive Owner: Chief Medical Officer Original Policy: 6/4/13 Current Effective Date: 4/5/16 Last Review Date: 5/06/14 Next Required Review Date: 4/5/17 This policy applies to the Medical Staff Office. I. POLICY STATEMENT It is the policy of Presence Covenant Medical Center and Presence United Samaritans Medical Center that the Medical Staff Office is the primary contact for any schools or individuals prior to any individual job shadowing or observing a physician or licensed independent practitioner at Presence Covenant Medical Center and Presence United Samaritans Medical Center facilities. All faculty and students participating in job shadowing or observing will follow the policies and procedures of Presence Covenant Medical Center or Presence United Samaritans Medical Center when job shadowing or observing. II. PURPOSE The purpose of this policy is for Presence Covenant Medical Center or Presence United Samaritans Medical Center to contribute to the learning experiences of potential future medical practitioners by considering requests for shadowing or observing a physician or licensed independent practitioners. This policy applies to pre-med or medical students attending a school or program not covered under a clinical affiliation agreement. III. MISSION / VALUES RATIONALE This policy is consistent with and furthers the Presence Health Mission and the Values of Honesty, Oneness, People, and Excellence. We provide Honesty in our interactions with the people that we serve. Our ability to work together demonstrates Oneness. People are the heart of our service, and Excellence is the manner in which care to our patients and their families is delivered. IV. DEFINITION For the purpose of this policy the following definition applies: A. Job Shadower / Observer is defined an individual, at least 18 years of age, who is enrolled in a pre-med program or medical school wishing to spend a short duration with a physician or licensed independent practitioner as a learning experience. B. Shadowing is defined as an educational activity limited to observation of Patient Care activities in the presence of a medical staff member.

2 Presence Covenant Medical Center Presence United Samaritans Medical Center Section: Medical Staff Office Page 2 of 2 Subject: Job Shadowers and Observers Not Covered Under Clinical Affiliation Agreement V. PROCEDURE A. Medical Students Job Shadowing or Observing: 1. Students who are currently enrolled in a pre-med or medical student program through an accredited college or university may be allowed to job shadow or observe with the approval of the Chief Medical Officer or designee. 2. Job Shadowing / Observing students are observing only and do not provide any level of patient care. 3. The job shadowing / observing duration will not exceed five (5) calendar days and must be accompanied by a member of the medical staff at all times during the job shadowing/observing experience. 4. Students shadowing or observing a medical staff member are not required to have written contracts. B. Medical Students/Observers Documentation Requirements: 1. All job shadowers/observers will complete a HIPAA agreement, confidentiality statement, and Standards of Behavior. 2. All job shadowers/observers will be issued a temporary (not to exceed five (5) calendar days) ID badge by Security. The Security Department will confirm with the Medical Staff Office the dates of the job shadowing/observation before issuing a temporary ID badge. The Security Department will indicate on the ID badge the dates of the shadowing/observing experience. 3. Unless in a restricted access area requiring special attire, job shadowers/observers will wear appropriate attire as directed by the Medical Staff Office. 4. Job shadowers/observers are not permitted to sign or witness the signature of any legal paper or document. 5. Job shadowers/observers may not sign as a witness on a consent form. 6. Job shadowers/observers may not take written or verbal orders. 7. Job shadowers/observers are not allowed to document any patient care record. 8. Job shadowers/observers will not provide any patient care. C. Verification Forms: 1. The required documentation as listed above will be maintained in the Medical Staff Office for all job shadowers/observers. VI. IMPLEMENTATION FORMS AND OTHER DOCUMENTS Confidentiality Agreement/HIPAA Agreement Student Health File completed (current TB, MMR, Varicella, Hepatitis B, and Proof of Flu Vaccination) Shadowing a Medical Staff Member Form VII. VIII. RELATED SYSTEM OR MINISTRY POLICIES REFERENCES

3 SHADOWING/OBSERVING A MEDICAL STAFF MEMBER Name: Last First M.I. Birthdate: (Must be at least 18 years of age.) Photo Identification: Please attach a copy of valid government issued identification. Student Health File: Must attach documentation demonstrating current TB, MMR, Varicella, Hepatitis B and flu vaccination. Name of Pre-Med or Medical School: Physician to be Shadowed: Shadow/Observe Dates (Not to exceed 5 calendar days): In signing this form I agree to be bound by the terms as outlined below. All job shadowers/observers will complete a HIPPA agreement, confidentiality agreement and Standards of Behavior. All job shadowers/observers will be issued a temporary (not to exceed 5 calendar days) ID badge by Security. Unless a restricted access area requiring special attire, job shadowers/observers will wear appropriate attire as directed by the Medical Staff Office. Job shadowers/observers are not permitted to sign or witness the signature of any legal paper or document. Job shadowers/observers may not sign as a witness or on a consent form. Job shadowers/observers may not take written or verbal orders. Job shadowers/observers are not allowed to document any patient care record. Job shadowers/observers will not provide any patient care. No health care benefits, workers compensation, or other benefits are provided by the Hospital in the event of illness or injury. Job shadowers/observers may not use their supervising physician s computer access code(s) in the hospital Applicant Signature Date Signature of Physician to be Shadowed/Observed Date Please submit completed documentation to the Medical Staff Office. Medical Staff Office will make arrangements for obtaining an ID badge.

4 CONFIDENTIALITY AGREEMENT Instructions To be completed by employees, medical staff, students, volunteers, vendors, business associates, and any others who are permitted access to the Presence Health Confidential Information. I UNDERSTAND AND AGREE THAT IN THE COURSE OF MY WORK WITH PRESENCE HEALTH I WILL MAINTAIN THE PRIVACY, CONFIDENTIALITY AND SECURITY OF ALL PRESENCE HEALTH CONFIDENTIAL INFORMATION IN ACCORDANCE WITH THIS CONFIDENTIALITY AGREEMENT AND ALL APPLICABLE PRESENCE HEALTH POLICIES AND PROCEDURES ( PRESENCE HEALTH POLICIES ). Definition of Confidential Information ( CI ) I understand that CI includes: Confidential and/or proprietary information about Presence Health Network and its affiliates Information from any source and in any form, including, paper record, oral communication, audio recording, and electronic display. Patient Protected Health Information ( PHI ), including information in medical records, billing records, and conversations about patients Personnel information, including payroll, discipline or other information about employees, volunteers, students, contractors, or medical staff Confidential business information of third parties having a relationship with Presence Health, including information about third-party software and other licensed products or processes, operations, quality improvement, peer review, education, billing, reimbursement, administration, or research (such as utilization reports, survey results, and related presentations). Access/Use/Disclosure Agreement I understand and agree that with respect to any CI to which I am granted access: 1. For Job-Related Purposes Only. I will only access, use and disclose CI for a legitimate job-related reason and strictly on a need-to-know basis, and that I will limit my access, use and disclosure to the minimum amount necessary to accomplish the legitimate intended purpose of the access, use and disclosure. 2. PHI Privacy/Security. I will protect the privacy, confidentiality and security of PHI, including all PHI in electronic medical records ( EMR ), in accordance with legal requirements and Presence Health Policies. 3. Business Associate Agreement. I understand that if I am a vendor that will have access to PHI in the course of performing services for Presence Health, a Business Associate Agreement must be signed by me or my company prior to me and/or my company receiving access to PHI. 4. Training. I will complete all required privacy and security training for accessing EMR or other CI. 5. Inappropriate Access. I will not access or obtain my own, a friend s, or a family member s information maintained by Presence Health without appropriate written authorization and consistent with Presence Health Policies. 6. No Use of Mobile Device/Removable Media. I will not maintain CI on any mobile device (laptop, smartphone, tablet, etc.) that is not encrypted, will not electronically transmit CI in an unsecured manner or to an unencrypted mobile device and will not copy and store any CI on any removable media (e.g. flash drives). 7. Protection of Credentials. I will not disclose to another person my sign-on code and/or password, and will not use another person s sign-on code/password for accessing EMR or other CI. I will not leave a secured application unattended while I am signed on. 8. Secured Application. I will not attempt to access a secured application or restricted area without proper authorization or for purposes other than official Presence Health business. 9. No Unauthorized Copying/Alteration/Destruction. I will not copy, alter or destroy CI unless such action is part of my job or the services that I am responsible for providing to Presence Health, in which Sponsored by the Franciscan Sisters of the Sacred Heart, the Servants of the Holy Heart of Mary, the Sisters of the Holy Family of Nazareth, the Sisters of Mercy of the Americas and the Sisters of the Resurrection

5 case I will only copy, alter or destroy CI in accordance with applicable Presence Health policies and procedures. 10 Reporting of Issues. I will immediately report to my supervisor or the appropriate Presence Health representative responsible for overseeing the provision of services by me and my company any known or suspected (a) use of my password by someone other than me, or (b) inappropriate access, use or disclosure of CI. If my supervisor or responsible representative is not available, I will notify the System Compliance Officer and/or Privacy Officer. 11. Safeguarding Presence Health Property. I will safeguard from loss, theft, or unauthorized use, disclosure and access all Presence Health owned equipment/property that is placed in my control and on which CI is stored or through which CI may be accessed. 12. Use of Personal Equipment/Property. I will not store or transmit CI via my or my company s personal equipment/property unless permitted by and in accordance with applicable Presence Health Policies. If any Presence Health PHI is stored or transmitted with my or my company s equipment/property, I will ensure that all such CI is properly encrypted in accordance with HIPAA encryption standards. 13. No Social Media/Blogging. I will not post or discuss CI of any type on any social media sites, blogs, discussion groups and the like unless pre-approved by Presence Health. 14. No Recordings. I will not take photographs, make videos, or make other recordings of patients, staff, or visitors except in accordance with applicable Presence Health Policies. 15. Auditing. I understand that my access to CI and my Presence Health and other information system accounts may be audited. 16. Ownership of Information. Presence Health will retain ownership of all rights, title and interest in and to the CI and no rights are transferred to me by virtue of my access to CI. 17. Return of Information/Continuing Obligations. I WILL RETURN ALL CI TO PRESENCE HEALTH AND WILL NOT TAKE ANY CONFIDENTIAL INFORMATION WITH ME WHEN MY WORK AT PRESENCE HEALTH ENDS. I UNDERSTAND THAT EVEN AFTER MY WORK ENDS I WILL CONTINUE TO BE REQUIRED TO KEEP ALL CI TO WHICH I HAD ACCESS CONFIDENTIAL. I have read, understand and agree to comply with the terms of this Confidentiality Agreement and all applicable Presence Health policies and procedures. I understand that my failure to comply with this Confidentiality Agreement may result in termination of access to Presence Health systems, disciplinary action, up to and including termination of employment or student status, loss of Presence Health privileges or contractual or affiliation rights and/or legal action. Name: (Please print) Signature: Date: