[Lanette]

I need some help, we had an incident, and I do not know what to do. I was getting the info I needed for my patient i=on the floor I had clinical the next day, A fellow student that works on the floor copied some med sheets for me, ahe whited out the name, medical record number, and nurses signatures, after they were copied. One of the nurses that works on the floor saw her and questioned us. The med sheets were taken off the floor(the copied ones), and brought back the next day and disposed of. The nurse went to the manager of the floor,and causes a problem. The student went to her assistant manager and told her what happened and she told her as long as the medical record number was whited out there was no problem. The incident was reported to our instructor, and is being investigated. Do I have cause to worry as much as I am???
Lanette

[llg]

At my hospital, students are not allowed to take medical records off the floor without special permission -- even if they white out the names, etc. It's just too hard to police everyone to be sure that there is no HIPAA violation and if lots of people start doing that, someone will slip up sometime.

Now ... since you can reassure them that no harm resulted from your actions, I would recommend that the hospital and your school use this as a learning experience and go easy on you. These types of incidents help to identify potential "holes in the system" and illustrate the need for some changes in procedures and/or additional education. As such, they should be handled in a way that encourages people to report them and be honest about what happened and why. That's the best way to ensure that no harm is done to this patient or any future patients. But by law, the hospital and the school must both investigate this possible HIPAA violation.

llg

[Julielpn]

We are allowed to print out the MAR and as long as we cut off the part where the pt name is, we may take it home to research our meds. Maybe in the future, the name and pertinent information part could be completely removed.
Good luck to you! (I think you'll be alright.)

[RNin2007]

Same goes for our school. We are not allowed to remove any PT records, even with the names whited out. We are not even allowed to make photocopies with the name whited out to use IN the hospital. Like the first poster said...it's a HIPAA thing. Did your instructor tell you not to do this or did you check to see if you could do this before it was done?

~J

[Daytonite]

What has the nursing instructor told you guys with regard to looking through a patient's records? If she told you not to take xerox copies of anything, then you need to worry. Always follow the rules your clinical instructor has given you. Otherwise, I don't see a problem with taking all identifying information off a copy of a medication record. You can save a bunch of time and white out by using little sticky notes placed over the patient's name and the nurses signatures before xeroxing. They can then be removed and thrown away.

[EMTtoRN]

I guess it all depends on your school. We are allowed to make copies and are provided with the MAR with all pt info blacked out

[mariedoreen]

We're told explicitly not to do it. I know students who do and try to encourage me as it saves a ton of time. I'm envious as I see them racing off the floor an hour before me, but I'm not going to risk trouble. I agree with Daytonite, it all depends on what you've been told. If I were you I'd also take a look in my nursing program handbook and see what it has to say...

[klone]

We're allowed to photo copy pages from pts. files (med sheets, kardex and labs). We can cut off, white out or black out with a Sharpie the pt's name.

[LeesieBug]

We are allowed to print labs as long as we black out the pt name, #, with a permanent marker before leaving the floor.

I agree that the seriousness here depends completely on your school's and the hospital's policies. We we told VERY specifically what we could and could not take home. Photocopying anything in the chart would be a big no-no for us.

[JessicRN]

There are 2 questions to answer. What is your school and hospital policy, and did you know what the policy was. Students are not perfect they make mistakes if no one is harmed, it should be treated as a learning experience,how else do they get better in my opinion, that is why they need to be supervised so strictly. When in doubt ask. Hope were superiors feel the same way good luck. Heck they present pts in grand rounds and tumour boards the way you describe, why shouldn't you.