[toosun]

I'm graduating with a BSN (accellerated) in a few short months
and have made what I think is a really good "brain"
for myself.

I feel that if I keep all my notes and vital pt
information in one place I can more easily chart,
avoid errors, and give accurate reports.

I'm setting myself up for some redundant paperwork
and I realize these will not be legal documents.

But my question is should I keep them anyway?
I can easily cut off the pt names befor leaving
the hospital and conform with HIPAA

But would a stack of these papers be off any potential use
in covering my backside ex post facto?

By the way, I'm 49 years old, delighted with my new career choice,
and looking forward to med-surg nursing.

To all you veterans I for wisdom

Thanks

[PsychRN03]

Originally Posted by toosun

I'm graduating with a BSN (accellerated) in a few short months
and have made what I think is a really good "brain"
for myself.

I feel that if I keep all my notes and vital pt
information in one place I can more easily chart,
avoid errors, and give accurate reports.

I'm setting myself up for some redundant paperwork
and I realize these will not be legal documents.

But my question is should I keep them anyway?
I can easily cut off the pt names befor leaving
the hospital and conform with HIPAA

But would a stack of these papers be off any potential use
in covering my backside ex post facto?

By the way, I'm 49 years old, delighted with my new career choice,
and looking forward to med-surg nursing.

To all you veterans I for wisdom

Thanks

I'm totally not a pack rat, but I would keep them, esp. if you have a pt. that dies while on your floor or if the family/pt. threaten litigation, and you took care of them at any time during their hospitalization. Although your "brains" aren't a legal doc in terms of the medical chart, I have heard of nurses using these types of documents successfully to defend themselves in a courtroom. I'm not saying you can rely on them solely to protect your license, but I believe they can pick up where your laborious charting leaves off. And look at it this way; simply get an empty paper box and that's all you have to use to store them away neatly.

[allthingsbright]

Originally Posted by toosun

I'm graduating with a BSN (accellerated) in a few short months
and have made what I think is a really good "brain"
for myself.

I feel that if I keep all my notes and vital pt
information in one place I can more easily chart,
avoid errors, and give accurate reports.

I'm setting myself up for some redundant paperwork
and I realize these will not be legal documents.

But my question is should I keep them anyway?
I can easily cut off the pt names befor leaving
the hospital and conform with HIPAA

But would a stack of these papers be off any potential use
in covering my backside ex post facto?

By the way, I'm 49 years old, delighted with my new career choice,
and looking forward to med-surg nursing.

To all you veterans I for wisdom

Thanks

Actually, I know several nurses who keep their brains in their locker at work as a CYA type back-up plan (that way they comply w/ HIPAA and dont have to remove names because the brains arent leaving the building). Could be a good idea!

[RedRobin8]

My mother worked in a different field (supervisor of police emergency communications) and kept a personal journal of the ongoing personnel issues, employee 'attitudes' and other noteworthy events. It was subpoena'd as corroborating evidence of poor behavior concerning an employee who left and started some unsubstantiated legal issues. It certainly cannot hurt to retain this information, and may just help you or someone else down the road.

[aeauooo]

Keeping your brains will NOT help CYA - they can get you into even more trouble than if you hadn't kept them.

If you keep them and you are called to testify, you will be asked if you kept notes. If you say yes, they become discoverable documents and you will have to submit them as evidence - bad idea. If you deny their existence, you have committed perjury - also a bad idea.

Put them in the shred box where they belong.

CYA in your documentation - that's what it's for.

[psalm]

I have kept a copy of an incident report where I reported a physician. I wanted to have a copy of it in case it was "lost" by management. It concerned pt. care, but I blocked out the pt. name. This doc is very testy...he will cast blame on the nursing staff any way he can. Our NM has had to deal with him enuff that he is known for this.