(PIA Annotated Template - Section C)
Document Purpose and Overview
A Privacy Impact Assessment (PIA) describes how proposed administrative practices or information systems may affect the privacy of the individuals who are the subjects of the information.
This document is intended to be adapted by the custodian when submitting a PIA in Section C: Health Information Listing Table. This table provides the Office of the Information and Privacy Commissioner (OIPC) with a list and description of the types of health information you will collect, use or disclose. Keep in mind the Health Information Act (HIA) requires that custodians only collect, use, and disclose the amount of health information that is essential to meet the intended purpose.
The proper form to use is the PIA Annotated Template. This template is intended to assist community-based custodians in completing PIAs. It can be accessed on this page on the Alberta Health website.
Instructions for Use
- Below is an example of how to create a Health Information Listing Table
- Develop a table that resembles your clinic's processes
- Once complete, this table can be inserted in the Annotated Template with your clinic specific information in it in Section C – Project Privacy Analysis
Example
Health Information Listing Table
This table lists the common health information collected in a community clinic. Add this document into the Section C of the Project privacy Analysis when completed.
| Health Information Listing Table | ||
| Registration Information | Diagnostic, Treatment & Care Information | Scheduling/Billing Information |
| Patient name* Address Phone number (home) Phone number (work) Additional contact numbers (cell, pager) Gender Date of birth Personal Health Number* Contact name Contact relationship Contact Address Contact phone numbers (home, work) Alerts Pharmacy Chart Number* |
Family and social history Past medical history Immunization history Medications Allergies Lab orders and results Problem list Vital Stats Progress notes Consults Diagnostic imaging reports Health service provider information (physician name, provider ID*; referring physician name, referring Dr. ID) |
Appointment date Appointment time Reason for visit Payer Amount owing Units Provider ID* Referring Dr. ID* Service facility Functional centre Date Originating facility Originating location Hospital admit date Comments Pay to entity |
*Unique Identifier
Learn@AMA Training
Enrol your medical clinic in AMA's free privacy training tailored to physician, privacy officer and staff roles through Learn@AMA sign-up your whole community-based clinic team today!
Enrol Today!Developed by
