Bringing home notes on pt. care??

Cuddleswithpuddles · May 9, 2014

If it is so significant that it influences legal proceedings, why not just document it in the patient's chart in the first place?

I do not understand keeping personal notes on patients for legal protection. If one were to keep them anonymous, one would have to put initials, pseudonyms and basically anonymize the data to the point where a lawyer could question whether the note actually referred to the patient or incident the nurse claimed it is about. If they are so specific that it could influence a legal decision, would the nurse get in trouble for keeping such sensitive data at home where he or she may not be authorized to keep patient information? And, again, why not just document it appropriately in the chart or report to management?

kiszi, RN · May 9, 2014

agree with pp. Seems keeping a mountain of info at home to jog one's memory "just in case" of a lawsuit is paranoid and unnecessary, not to mention that it does indeed cross the boundaries of pt. confidentiality. Always be in the habit of charting well and let your charting speak for itself.

psu_213, BSN, RN · May 9, 2014

If one were to keep them anonymous, one would have to put initials, pseudonyms and basically anonymize the data to the point where a lawyer could question whether the note actually referred to the patient or incident the nurse claimed it is about.
And, again, why not just document it appropriately in the chart or report to management?

We had a similar discussion on here before about this. I believe those who know more about the law and courts than I do told us that if it is discovered that you are keeping notes of you own about pt care, and you are using that information in your testimony, then said documents could be entered as evidence. If this is true, I could see how this could cause someone who is peripherally involved in the case to be accused of wrong doing and be thrust into the center of the case.

I agree, chart it!. If it is important, it should be in the chart. If I am unable to recall the case from my charting, this is my failing….notes I keep at home will not help.

RNsRWe, ASN, RN · May 9, 2014

"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."

I have to wonder about your instructor (and anyone else who thinks this is a good idea). Miscellaneous notes on hundreds, THOUSANDS of patients filed away in your home? Private medical information about strangers that is not protected from anyone who stumbles across it? Ridiculous.

If you do somethat that warrants charting, CHART it. Don't squirrel it away in your house! I can only imagine seeing a warrant for the searching of an entire home for any nurse who is suspected of keeping such information "just in case". And a warrant would absolutely be issued, because the nurse herself had made it known that she kept private medical info on her patients "just in case". As in "just in case the prosecution wants it"!

Chart what is valid to chart. Take home ZILCH.

Cuddleswithpuddles · May 9, 2014

We had a similar discussion on here before about this. I believe those who know more about the law and courts than I do told us that if it is discovered that you are keeping notes of you own about pt care, and you are using that information in your testimony, then said documents could be entered as evidence. If this is true, I could see how this could cause someone who is peripherally involved in the case to be accused of wrong doing and be thrust into the center of the case.

I see. What happens if lawyers ask for my entire stash of notes? If I volunteered one snippet I felt was relevant to my (or their) case, could I be ask to turn over all of it?

This is all hypothetical of course. I sometimes make note of work happenings in my personal diary, but not with the intent of using it in legal defense.

All of this makes me remember The Office where Michael Scott's diary was used in a deposition, including his personal remarks about sex with Jan and his man-crush on Ryan. LOL.

2bAngilRN · May 9, 2014

"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."
I have to wonder about your instructor (and anyone else who thinks this is a good idea). Miscellaneous notes on hundreds, THOUSANDS of patients filed away in your home? Private medical information about strangers that is not protected from anyone who stumbles across it? Ridiculous.
If you do somethat that warrants charting, CHART it. Don't squirrel it away in your house! I can only imagine seeing a warrant for the searching of an entire home for any nurse who is suspected of keeping such information "just in case". And a warrant would absolutely be issued, because the nurse herself had made it known that she kept private medical info on her patients "just in case". As in "just in case the prosecution wants it"!
Chart what is valid to chart. Take home ZILCH.

I do not believe it is private medical information. I believe she made notes on the care she gave to the patient. I believe if doctors orders were not carried out or medications not given based on her critical thinking skills she wrote personal noted for her own record. From reading the responses I need to get in contact with the instructor for further clarification.

RNsRWe, ASN, RN · May 9, 2014

I do not believe it is private medical information. I believe she made notes on the care she gave to the patient.

It would be my interpretation that acknowledging care done for a patient IS private information; the fact that John Doe was ever a patient is private....and that he had XYZ procedure is private, so....yes, I would argue that a record of Nurse Smith emptying/pulling John Doe's JP after his XYZ procedure would be private.

And honestly? A HUGE can of worms. I stand by "chart what's relevant". Not your opinions, not what you think someone else should have done or not done...only what you DID do, and WHY.

psu_213, BSN, RN · May 9, 2014

I believe if doctors orders were not carried out or medications not given based on her critical thinking skills she wrote personal noted for her own record.

If a doctor's order is not carried out for any reason, chart said reason. For example, "HR 52, Metoprolol held, Dr. Smith notified." "Chest tube dressing not changed per pt request. Instructed pt on the risks of not having the dressing change, including risk of infection…etc."

psu_213, BSN, RN · May 9, 2014

I see. What happens if lawyers ask for my entire stash of notes? If I volunteered one snippet I felt was relevant to my (or their) case, could I be ask to turn over all of it?

I'm not exactly sure of what exactly has to be turned over (I'll leave that to the more legal-system savvy on here), but consider this scenario:

Attorney: "You stated that you turned bed alarm off because the patient requested it not on and that they promised not attempt to get out of bed. How do you remember that from 5 years ago when it is not in the chart? Did you happen to keep notes on this patient?"

Nurse: (under oath) "Yes, I keep pertinent notes about patient care and keep them in a safe place in my house."

Attorney: "So, you are telling me that you keep notes on patients at your home? Are you not aware that those notes contain confidential information that you have now put in a place where others can stumble across it?"

Nurse: "I don't identify the patient on those notes, just refer to them by initial."

Attorney: "I see. So your notes at home have the initials "L.O." on them for my client Lauren Osborne? What if those are actually your notes on Louis O'Brien?"

It just isn't worth keeping notes and can cause a lot more trouble than they are worth.

Here.I.Stand, BSN, RN · May 9, 2014

I do not believe it is private medical information. I believe she made notes on the care she gave to the patient. I believe if doctors orders were not carried out or medications not given based on her critical thinking skills she wrote personal noted for her own record. From reading the responses I need to get in contact with the instructor for further 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."

2bAngilRN · May 9, 2014

I'm not exactly sure of what exactly has to be turned over (I'll leave that to the more legal-system savvy on here), but consider this scenario:
Attorney: "You stated that you turned bed alarm off because the patient requested it not on and that they promised not attempt to get out of bed. How do you remember that from 5 years ago when it is not in the chart? Did you happen to keep notes on this patient?"
Nurse: (under oath) "Yes, I keep pertinent notes about patient care and keep them in a safe place in my house."
Attorney: "So, you are telling me that you keep notes on patients at your home? Are you not aware that those notes contain confidential information that you have now put in a place where others can stumble across it?"
Nurse: "I don't identify the patient on those notes, just refer to them by initial."
Attorney: "I see. So your notes at home have the initials "L.O." on them for my client Lauren Osborne? What if those are actually your notes on Louis O'Brien?"
It just isn't worth keeping notes and can cause a lot more trouble than they are worth.

Lol! I like your script of nurse and attorney