Documenting ICD Codes and Other Sensitive Information in Electronic Health Records

In 2018, the CDC adopted new ICD codes (created by HEAL Trafficking and other stakeholders) to describe human trafficking (HT). These specific HT codes allow healthcare professionals and others to optimize continuity of care for trafficked persons, determine health needs and effective treatments for HT-related health conditions, track cases of HT to assist in ensuring adequate resources are provided to communities, and inform local and national prevention and intervention policies. However, in some cases use of violence-related codes (e.g.,HT, intimate partner violence, child sexual abuse) could pose a threat to patient and staff safety, and patient confidentiality.

The following guidelines were developed by a subcommittee of stakeholders, including survivors of labor and sex trafficking, and were written to reflect a trauma-informed, rights-based approach. The guidelines aim to educate HCPs about how to work with trafficked/exploited/abused patients when making decisions about use of ICD codes and documentation of sensitive information in the electronic health record (EHR).

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