Anyone An Hippa Expert Re: Hospital Staff Access To Charts??

  1. When I work at the hospital I sometimes see care partners and unit secretaries reading a patient's H&P. It's not necessarily a patient they're taking care of. Sometimes it seems like it's snooping and not needed for the care of the patient. To me this is a violation of HIPPA. What do you think?

    Since HIPPA has been enacted, has it cut down on care partner access to reading of patient charts?
    What I understand is access is for what you need to do your job. I had a CP today open a chart looking at the admit sheet, orders, and the H&P. She usually goes through one or two charts a day. What she told me is she's part of nursing and in the past has had access to all the charts then stormed off! I don't access charts of patients I'm not taking care of.:smilecoffeecup:
    I don't feel like a nurse is the only one to access the chart but sometimes there are CPs looking at a chart especially if the pt. has a pysch problem, but the CP isn't taking care of that pt.
    Our CPs do no charting in the charts.
    Just wondering what your policy is or if there isn't one, do you have a similar situation?
    Last edit by sirI on Feb 10, '07 : Reason: merged duplicate post with original post
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  2. 34 Comments

  3. by   leannek90
    I agree with you. The private information that is included in a patient chart should only be seen by the people who are responsible for their care. I am dealing with this issue with one of our unit secretaries. I work on a labor and delivery floor, and often I see her looking through the chart that she just pulled for the next patient that is coming in, and on her way to the nurses desk, she is reading all kinds of private information that is in the chart. How many pregnancies, her age, drug use, abuse. Then she wants to chat about it! Like, " oh my gosh, this girl has been pregnant 6 times, had 4 abortions, and she's only 23!" Guess what? As a secretary, it's none of your business!! I have spoken to her a couple of times by saying, "you know, it's really not appropriate for you to be reading the patient's charts. It's confidential information." Once she replied, "oh but I was just seeing if you needed an update from the clinic on this patient." Well, again, I, as the NURSE will ask you to call the office for an update if it is necessary.

    Ok, I'll get off my high horse now.

    I just know that I wouldn't want just anyone to get ahold of my medical records and feel at will to read them!
  4. by   Batman24
    I would hate to think that someone would invade my privacy like that. My health info should only be read by those caring for me.
  5. by   jennyfyre
    I am a unit coordinator on a peds/gyn unit, and I agree. I only read what is necessary for me to do my job. Also, no comment needs to be made on what I have read, even if it surprises me. I sometimes have to search progress notes to make sure the patient has been seen by consulting docs and they have documented their visit, but I have no need to know the details. I just look to make sure there is a note, before I make an unnecessary call to remind them to see the patient. One of the duties now assigned to unit coordinators in my hospital is part of the pre-op checklist. For that I have to hunt thru records for ekg's, previous heart/ blood issues, previous surgeries and the anesthesia records, etc. That makes me a little nervous sometimes.. like I have to investigate them fully before surgery!
  6. by   KellNY
    Our CAs (hospital setting) are allowed to go through the chart. I know that the other RNs and myself appreciate this because it contains a lot of information, and will help you to understand why we're doing what we do (Ie why I&O if no IV and no renal issues? Why finger sticks if no diagnosis of DM? Why it's so important to keep her on hre right side, etc).

    HIPAA allows for those involved with the Pts medical care to access medical information, and that includes CAs from that unit.

    Now, if you wanted to go down to peds and read through the chart of an abuse victim you read about in the paper, or to Psych to look through the chart of an accused rapist you saw on the news last night, well, that would obviously be a different story.
  7. by   Tweety
    First of all, can you or someone else who comes along tell me what a "CP" is?

    I agree with you, it's only as "a need to know" basis. Some people who don't take direct care of the patient, or who do not chart in the chart still can access it. For example, the insurance company, a case manager from a nursing whom is evaluating whether or not they will accept the patient, etc.
  8. by   ginger58
    Quote from Tweety
    First of all, can you or someone else who comes along tell me what a "CP" is?

    I agree with you, it's only as "a need to know" basis. Some people who don't take direct care of the patient, or who do not chart in the chart still can access it. For example, the insurance company, a case manager from a nursing whom is evaluating whether or not they will accept the patient, etc.
    Hi. CP is what my hospital calls what used to be called a nurse's aide. I guess I really wonder if a CP needs to read a chart daily on "a need to know basis." I'm not sure some of the people know what they're reading. A supervisor said to me that it was OK because some of the CPs are going to nursing school!
    Last edit by ginger58 on Feb 10, '07 : Reason: CP=care partner
  9. by   SuesquatchRN
    Aides are not allowed access to patient charts.
  10. by   Franksters
    The only information nursing assistant needs, is what WE tell them. They have absolutely no business in the charts.
  11. by   KellNY
    Quote from Suesquatch
    Aides are not allowed access to patient charts.
    Why is that? They are providing care, and whether or not they're going to nursing school doesn't matter to me.

    I mentioned on another thread asking this question-I find that the CNAs who look through the charts are able to provide better patient care. I work ante, and those that skim the charts and can see that the Pt has had 5 late term miscarriages and no living children aren't going to ask if the Pt has any other children who will become big brother/sister.

    Or that the CNA understands the importance of a certain positioning or whatever.
  12. by   KellNY
    Quote from Franksters
    The only information nursing assistant needs, is what WE tell them. They have absolutely no business in the charts.
    Wow. Can you explain that opinion to me?
  13. by   Cattitude
    i've never in any hospital seen an aide reading a chart. not their business.
    [color=#483d8b]now in home care we don't even tell the aides what dx, of pt. is.
    [color=#483d8b]
    [color=#483d8b]
  14. by   Tweety
    CNA's sometimes need to look into a chart to clarify a diet order, activity status, or something like that. So to say CNA's have no business whatsoever in a chart, doesn't quite ring true.

    An example would be, a patient who is NPO is delivered a meal tray. The nurse might not be around, so the CNA checks the orders to see if it's changed. Or a patient during a bath says "the doctor says I can get in a wheelchair and leave the unit". Stuff like that.

    Again, there must a "need to know" search for information.

    But for the most part CNA's don't need to access too much of the chart.
    Last edit by Tweety on Feb 10, '07

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