[rb101]

What do you think about a manager asking for my notes I take during a telephone report so he can save it "to show to JCAHO?"
The manager also wants everyone to use the same "brains" instead of letting each nurse use what they are most comfortable with.
Legally can I be forced to give my personal notes to anyone? I always thought they were just for my personal use to help me organize my report and to answer questions the patient or the doctor might have throughout my shift. I am not signing them so they are not a legal document, right? Then how can JCAHO be authorized to view them? I personally use slang abbreviations such as "MJ" for marijuana use and things like "noncompliant" that I don't really want others to see.
What do you think?

[AngelfireRN]

If your manager is going to save evry note that every nurse writes about every new patient, I hope they have a lot of extra filing space. Writing a report for your use should not be subject to a prescribed format, as long as all pertinent info is there. Is there a policy that states you have to give it to the manager? If not, I would politely tell him/her that these were my personal notes, not part of the patient's permanent chart, and therefore, not subject to JCAHO review. Good luck.

[joprasklpn]

I would think they are for your personal use. They don't provide the paper you use right? I worked at a place that saved aide note sheets that they provided. Why I will never know.Tell him to make his own notes.

[cardiacRN2006]

If they want, I might re-write report on some standardized report sheet later, but I still take report on a blank piece of paper-and no, they cannot have it.

[Emmanuel Goldstein]

You might want to talk to your hospital's legal department and risk management. Many of our nurses were keeping notebooks and saving computer-report sheets; we were told that even though these notes are not considered part of the medical record, they can be subpoenaed and used against you in a suit.

I never save anything past my shift. Everything goes into the shredder.

[caliotter3]

I read in a nursing journal once an admonition against keeping a journal/notes for the reasons that Emmanuel stated. The plaintiff's attorney can subpoena all of your notes or journal, not just the parts that pertain to the patient litigating against you. The article also stated that "journaling", per se, about things at work should only be shared with a therapist where there is a confidentiality relationship. I informed my attorneys about this when I was involved in a lawsuit and informed them that was why I don't keep notes and it was also of interest to them that my apartment had been entered around the time of the start of the lawsuit.

I wouldn't give my shift notes to management. As far as I'm concerned, they would have them available to use against me in the future, if they desired. My chicken scratching is only useful to me and I don't want it going anywhere else, courtroom or otherwise. What I put in the chart is what I want said about the matter. There are just too many ways to get into trouble.

[Emmanuel Goldstein]

Originally Posted by caliotter3

I read in a nursing journal once an admonition against keeping a journal/notes for the reasons that Emmanuel stated. The plaintiff's attorney can subpoena all of your notes or journal, not just the parts that pertain to the patient litigating against you. The article also stated that "journaling", per se, about things at work should only be shared with a therapist where there is a confidentiality relationship. I informed my attorneys about this when I was involved in a lawsuit and informed them that was why I don't keep notes and it was also of interest to them that my apartment had been entered around the time of the start of the lawsuit.

Good point. We were told that notes kept at home or away from work were still considered 'fair game'.

[Zookeeper3]

[


quote=caliotter3;2494662]I read in a nursing journal once an admonition against keeping a journal/notes for the reasons that Emmanuel stated. The plaintiff's attorney can subpoena all of your notes or journal, not just the parts that pertain to the patient litigating against you. The article also stated that "journaling", per se, about things at work should only be shared with a therapist where there is a confidentiality relationship. I informed my attorneys about this when I was involved in a lawsuit and informed them that was why I don't keep notes and it was also of interest to them that my apartment had been entered around the time of the start of the lawsuit.

I wouldn't give my shift notes to management. As far as I'm concerned, they would have them available to use against me in the future, if they desired. My chicken scratching is only useful to me and I don't want it going anywhere else, courtroom or otherwise. What I put in the chart is what I want said about the matter. There are just too many ways to get into trouble.[/quote]




Having been in a lawsuit, one of the first 30 or so questions was weather I took personal notes at any time in my career and had them on my personal belonging. Yep, they would be part of a suit.

Because of Jacho, we have a standardized form that we use for report, it becomes a permanent part of the record and satisfies the "sbar', or "edar" with transfers. this is a jcaho requirement and perhaps you can assist you facility with devising one.

Since every unit has the same form, when one unit transfers to another, it is smooth, just read and fill in the blank, when someone calls me in the ICU from the ER or floor, I just say hang on let me grab the paper and the info is given in a coordinated way in that everything pertinent is covered and I don't have to interrupt a bad report to ask questions.

It actually is a great new piece of paper, go figure.

[wayunderpaid]

I think some are confusing the organizing sheet that is used every day, and the report notes given during transfer of care over the phone.

Obviously, never, ever make available your organizing sheet to anyone, and yes, shred it after each shift. It has confidential information that should not leave the hospital.

Telephone transfer reports taken on the hospital provided forms are usually part of the chart. Where I work this is only done when a patient is coming from another unit, not when we receive report after a test (e.g. ultrasound, ct, etc.) Therefore, I am extremely careful about the kinds of abbreviations and the kinds of things I write on that form. If your hospital does not provide you with a form, I would not provide them with a written report. As simple as that.

Reports from end of shifts should not become part of any permanent record either, and I would kindly decline to give consent to anything that would jeopardize clinical information and judgments from a professional nurse to another. Absolutely confidential. Where I work, we have to sign confidentiality agreements to that effect, and I think that it is the right approach.

Wayunderpaid

[pagandeva2000]

I have personal notes, and I try hard not to have them viewed by management for reasons such as this. However, I am not surprized that a manager would try to take advantage and throw an employee out there in the frontlines for these surveyors. Once, when I was an assistant, they figured that since I memorized most of the information that Joint Commission wanted to use, they actually paged me to go to every clinic that they visited just in case they asked questions. I was like a yo-yo for two days.