Bringing home notes on pt. care??

Nurses General Nursing

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I am currently a nursing student and CNA. During nursing school I was told from a clinical instructor that she takes notes home on her patients. She told her story about a recent legal investigation done on her job concerning a patient she care for many years ago. All of the nurses who had taken care of this patient were being questioned as well. The instructor said she had to jog her memory about ALL the care she had given this patient during their stay at the hospital. She was able to conjure up some info. In the long run she was not found at fault for any wrong doing to the patient. She said its best to make notes, take them home, and file them away just in case some legal actions are in pursuit in the future. The instructor is not the first nurse I have heard say this.

My questions: is this legal and to what extent? What can be documented legally and taken home? Is this a HIPPA violation? Is the note a SOAP, SOAPIE, ADPIE, etc note? I need clarification.

But for her to remember who said note was about (out of possibly thousands of pts per year), she would have to have their name, date, etc. to even remember who she was talking about.

When I was in school, a classmate said an RN she knew took her brain sheet home every and filed it--just in case she were to get sued. This was during the "get liability insurance" lecture. Our instructor who did LNC work part-time responded "NO. That is a HUGE HIPAA risk to have all of that PHI in your home."

What's a brain sheet?

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Specializes in retired LTC.

Brain sheet = cheat sheet.

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I never did this in my career but I remember in my nursing school an instructor told us it is a good idea to keep a work 'journal' at home and write down anything out of the ordinary that happened on your shift. She said if there was a question about it you would have your notes to help you remember what happened and what you did. I don't know if that could somehow backfire against you or not. Like I said I have never done this but I can see it helping jog your memory if something came up a year or so later.

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Specializes in Pedi.

If something happens on your shift and it crosses your mind that the case might go to court, you BEST write a thorough nursing note IN the patient's chart/legal medical record, not on a scrap piece of paper that you're going to file away at home. Remember, "if you didn't document it, you didn't do it." A nurse is not going to look very credible if she claims to have all this information that she never documented in her own personal records.

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If something happens on your shift and it crosses your mind that the case might go to court, you BEST write a thorough nursing note IN the patient's chart/legal medical record, not on a scrap piece of paper that you're going to file away at home. Remember, "if you didn't document it, you didn't do it." A nurse is not going to look very credible if she claims to have all this information that she never documented in her own personal records.

We have always been taught to document everything during your care. There is no such thing as too much to documentation. However, I believe the instructor was implying to keep your own record as well. I'm assuming if something adverse or suspicious happened during your care. Like the above post mentioned to keep a work journal. Regardless, I just want to make sure I'm doing the best practice and clarify misunderstandings before I get myself out there.

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Specializes in SICU, trauma, neuro.
What's a brain sheet?

Report sheet w/ to-do list for the shift

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Specializes in NICU, PICU, PACU.

Take it from someone who has gone to court, don't do it. Make sure your nurses notes are concise and clear because that is what you will have to go by. I can't even imagine saying to the hospital lawyers, or surprising them on the stand, with information you have in your possession that is not part of the chart! The prosecuting attorney would have a field day.

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Specializes in pediatrics; PICU; NICU.

I've been a nurse for 36 years & have only had to give depositions twice. Both times the patient's chart was made available for us to review before we were asked anything. In both cases the depositions were several years after I had cared for the patient. I've always been very thorough with my documentation & every question I was asked had the answer in my notes. Because of the fact that everyone involved in the care of these patients had documented well, neither case was found to have merit & they were dismissed.

I would never keep any notes about patients at home. That's just asking for trouble. I think the same could be said for a "journal" because if it's discovered that you have that, it could be subpoenaed.

I've been working private duty for quite a few years & we aren't even supposed to have communication books for nurses to tell each other things because those can also be subpoenaed.

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We have always been taught to document everything during your care. There is no such thing as too much to documentation. However, I believe the instructor was implying to keep your own record as well. I'm assuming if something adverse or suspicious happened during your care. Like the above post mentioned to keep a work journal. Regardless, I just want to make sure I'm doing the best practice and clarify misunderstandings before I get myself out there.

Well, now you know what working nurses actually do, and what they think about your instructor's advice. Your choice at this point.

Going off on another note of this, I wonder what the litigation future might be for a nurse who is discovered to have a cache of information about patients at home (file, journal, whatever).....if one patient's info is subpoenaed by the prosecution, it will surely lead to OTHER patient's private information being viewed and possibly recorded by MORE people....and now each and every other patient who feels their medical information may have been compromised may have an action against that oh-so-careful nurse. Maybe by the same prosecutor who asked for the initial patient's info and finds himself with 900 patient's private medical info. Christmas!

And now that can of worms labeled 'HIPAA' is a swimming pool of worms.

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