Family looking through patient chart?(Sorry, kind of long...) - page 2

I am contracted out (self-employed) by this staffing agency as a private duty nurse. In the home we have a patient chart that looks like a typical chart in the nursing home. It has a plan of care,... Read More

  1. by   CHATSDALE
    leeway is given in in most places 30 min eith way for acute care and 1 hour before/after for ltc because everyone cannot get their meds at 9 am and a private duty nurse cqan give meds with a little leeway but this does not endorse pulling meds out before hand
    allowing a person with poa to read chart is certainly permissable..i can see no reason for withholding chart..if md doesn't want done it a order to that effect should be a person with poa should have same rights as patient
    this wman with the attitude should be talked to per poa and get them
    onsame side of the road
  2. by   pagandeva2000
    Quote from GingerSue
    lawyers do show up and look at patient files - I remember this happening in psychiatry

    - and yes, a patient's family member might alter documentation - I experienced this re: flow sheet left in the home, angry family member (out of control) had been shouting etc (which I documented on the home notes), and next day I saw that someone had taken a black marker to cover over my handwriting. (So, I wrote a detailed addendum on a separate sheet which I provided for my office, in which I explained what had occurred)

    I had a triplicate timesheet/systems sheet and nursing note sheet (that the client or parent has to sign) where one copy went to the family, another to the agency and the third copy for the nurse to keep. I also worried about the chance that family may alter the medical record, or read and disagree with what I documented. I had to be SUPER objective in my notes about the child that I cared for, who was, in fact, a discipline problem. As far as I know, the family didn't alter anything, but I am sure that if a situation arose, it is VERY possible to happen. Was not comfortable with that, but at least there was more than one document with the signature of the family member or client around.

    From what motorcycle mama was saying, this can easily happen, because of the fact that these documents are in the house, the nurse has NO control of them once she leaves. Any visitor or nosey person can happen to come upon this information. In the home, there is less privacy.
  3. by   leslie :-D
    it sounds like the nsg note sheets, should also be in duplicate/triplicate.
    at least in home health, anyway.

    leslie
  4. by   steelcityrn
    I just wanted to add, and maybe someone did alread , that if you have any questions as to who in the home can read the chart, just ask your employer. As for the family member that seems to be causing a problem, let the family deal with that. Never get in between that, you may be the one to get burned.
  5. by   pagandeva2000
    Quote from steelcityrn
    I just wanted to add, and maybe someone did alread , that if you have any questions as to who in the home can read the chart, just ask your employer. As for the family member that seems to be causing a problem, let the family deal with that. Never get in between that, you may be the one to get burned.
    But, think about it, the chart is in the home. Unless it is under lock and key, there IS no control of who can actually view it, diagnosis, treatments and all. Even if the nurse is there, unless she has it at her hip throughout her shift, there is no way to know who is looking. A child can spill juice on it. Company can visit for the holidays. The mother I worked for had an area in the closet where she wanted it to be, but many times, I found it on the kitchen table, living room couch, or on the dresser. Once, they had a birthday party for the child with over 20 children playing with some of the trach things, thinking they were toys.

    The case I worked for had 20 hours of nursing care a day, leaving 4 hours where no nurse was present. The family used to rearrange the furniture so many times, that each time I visited (I only went on Saturdays for a 10 hour tour), I had to find the trach things like a savanger hunt. Medications were moved around, so many things. I had to call the mother and put my foot down, telling her that the things that the nurses need should not be moved, or that a note should be placed on the refrigerator telling us of the new locations, so that we don't invade THEIR privacy by looking for things in odd places. I can see how this can become a real problem.
  6. by   Haunted
    Quote from steelcityrn
    I just wanted to add, and maybe someone did alread , that if you have any questions as to who in the home can read the chart, just ask your employer. As for the family member that seems to be causing a problem, let the family deal with that. Never get in between that, you may be the one to get burned.

    Excellent point made. On another note, I have always requested and been allowed to read a family or friends chart. The patient or family member gives the nurse verbal or written permission and I sit quietly at the nurse station and review, make a few notes and say as little as possible to ANYONE. I've found many a questionable item in there!

    Also, this family member/nurse is causing obvious problems, stress and chaos to the patient environment as well as the caregivers. If there is additional family around, I would have your supervisor bring it up with whomever contracted to provide care for the patient and explain that you have been providing excellent care for 2 years plus and this person is threatening and causing delays in treatment, confusion and undermining caregiver ability.

    And NO she may not view the chart without written consent. She will then only be able to view it in a monitored setting. If she wants copies, she can request them from patients PMD.
  7. by   mshultz
    Quote from woody62
    The only person who has the right to have access to the chart is the patient or the person holding a duly appointed Power of Attorney. No other member of the family has any right to read the chart unless the patient grants them written authorization. As for reading the patient's chart while hospitalized, the chart is the patient's record and he/she has the right to read it. That being said, hospital administration will attempt to delay access by putting all sorts of demands on the patient, including having another person, from the hospital present, and will charge for that person. If a patient wants copies of his hospital record, the hospital can charge normal and customary fees for duplication of the record. It generally runs from $1 to $3 a page. Hospitals will frequently withhold the chart claiming the record is incomplete.

    Woody
    My hospital records for 2003, that I requested in 2004, cost $30 for 72 pages. The people were nice, but acted as though I had made some sort of improper remark by requesting my records. She tried to scare me away from a complete records request by talking about how expensive it could be. It was not a pleasant experience.

    I Emailed the Patient Advocate in 2007 to ask how to obtain my X-rays, and a color photo of my colonoscopy. The reply said to contact the records department, which is what I had done in 2004. Although the colonoscopy color print was unavailable (I had given permission to take pictures because I expected to be given copies of any pictures, based on past experience :angryfire ), I received the X-rays at no additional charge.

    I wonder if this hospital will be more willing to provide clinical information to me in the future, since I have been so aggressive in requesting my records? They seem to be philosophically opposed to providing patient education.
  8. by   txspadequeenRN
    i would have called the cops on her. first she is interfering with my emergency. second she has no right to come in slashing orders and upsetting my patient even further. third, heck do we know for 100% sure she is a don. i mean she could work at the burger joint down the street. it don't matter who she is if she does not have poa or expressed consent from the poa or patient (if mentally competent) then she is just out of luck and just got her a chauffeured ride for acting like a fool.
  9. by   RNDreamer
    I agree...when I worked as a Home Health Aide, the plan of care was usually in plain site...most of my patients had it hung on their refrigerators...


    Quote from pagandeva2000
    But, think about it, the chart is in the home. Unless it is under lock and key, there IS no control of who can actually view it, diagnosis, treatments and all. Even if the nurse is there, unless she has it at her hip throughout her shift, there is no way to know who is looking. A child can spill juice on it. Company can visit for the holidays. The mother I worked for had an area in the closet where she wanted it to be, but many times, I found it on the kitchen table, living room couch, or on the dresser. Once, they had a birthday party for the child with over 20 children playing with some of the trach things, thinking they were toys.
  10. by   DutchgirlRN
    Quote from motorcycle mama
    Well...this patient happens to have a relative who is a big shot DON at a nursing home I met her one time and had to give her the attitude right back that she gave me and I hope I never have the misfortune of meeting her again. Anyway, the patient had a sinking spell/TIA and the day nurse on duty told me what happened with this relative and is worried and upset over it and I would just like to know if what I'm thinking is right.
    If you're in this patients own home then you need curb the attitude towards her family. You don't have to let anyone run you over but you can simply tune her out.

    This patient takes meds all through the day (for ex. 9am, 11am, 2pm, 5pm, etc.) and when the day nurse pulled the 9am meds she went ahead and pulled the 11am meds, set them aside in a cup and signed them out on the MAR.
    So, the hot shot grabs the MAR and when she sees that the 11am meds have been signed for she starts screaming at the day nurse, makes a big scene for the medics and all the world to see (you know, so everyone can see what a super nurse she is), saying things like don't you realize you could lose your license over this?
    The day nurse has no business mixing 9am and 11am meds. The latest the 9am meds should be given in 9:30 and the earliest the 11am meds should be given is 10:30 so I don't see her motive unless it's laziness. Goodness, only one patient to care for. I have done private duty with trached patients with loads of meds and I never had trouble giving meds on time. But it is hearsay...no complaint against you.

    I have also heard this supernurse has read through nurse's notes when she comes to visit the patient.

    Personality issues aside, is it in accordance with privacy laws and such for people (even family, and BTW, she isn't a child or grandchild) to look through patient charts when they have not been contracted out by this company to be involved in her care? It just doesn't seem right to me.
    The family has no business looking through the chart. There's no reason why they can't simply ask the nurse on duty how the patient is doing. Is the patient orientated? Just curious...she should have a say in this.
  11. by   woody62
    Quote from mshultz
    My hospital records for 2003, that I requested in 2004, cost $30 for 72 pages. The people were nice, but acted as though I had made some sort of improper remark by requesting my records. She tried to scare me away from a complete records request by talking about how expensive it could be. It was not a pleasant experience.

    I Emailed the Patient Advocate in 2007 to ask how to obtain my X-rays, and a color photo of my colonoscopy. The reply said to contact the records department, which is what I had done in 2004. Although the colonoscopy color print was unavailable (I had given permission to take pictures because I expected to be given copies of any pictures, based on past experience :angryfire ), I received the X-rays at no additional charge.

    I wonder if this hospital will be more willing to provide clinical information to me in the future, since I have been so aggressive in requesting my records? They seem to be philosophically opposed to providing patient education.
    The only time I have ever been angry with Sarasota Memorial was in 1999 when I requested to see my complete medical records from them. My records went back to 1990. They gave me a hard time saying they were out in a warehouse, in storage, and it would take them time to get them. I told them fine, you have five business days. Then they told me that I would have to have someone from their Medical Records Department sit with me, while I read my records and I told them what I wanted copied. And it would cost me twenty dollars an hour. I said, no thanks, I am an RN and I know what I am reading. And I will not pay to have someone sit along side of me. I had to have eighty pages copied and it cost me one hundred and twenty dollars. They charged me one dollar and fifty cents a page, which frosted me to no end. Now when I am admitted, I ask for a copy of my admitting history and physical, ER treatment, any consults, any x-rays and other special test I have to have plus my discharge summary. I still have to pay for them but now I get them without any argument.

    My parents had no problem getting any of our military medical records when my Dad was on active duty. Why do hospitals make it so hard for patients to get copies of their medical records? They act like we are trying to steal papers from the White House.

    Woody
  12. by   ginger58
    [QUOTE=crissrn27;2457391]Gotta disagree with you on this point. At least in my state, your medical chart is yours. You, and whomever you deem, may read your chart at anytime. No doctors "permission".

    HIPPA is a federal law, not state. The only person who can read their chart is the patient, unless the patient gives permission. In the hospital where I worked, the patient or family had to put in a written request to Medical Records and then there had to be a nurse or doctor present when looking at the chart. POA only takes over when the patient isn't competent to make decisions on their own.

    You need to reread HIPPA regulations as you could lose your license.
  13. by   Jo Dirt
    Quote from DutchgirlRN
    If you're in this patients own home then you need curb the attitude towards her family. You don't have to let anyone run you over but you can simply tune her out.
    No, you can't simply tune someone out who is in your face so don't tell me what to do about something when you don't know what the situation is like. It doesn't matter how accomodating you are to some people they will still spit in your face and I'm not going to apologize for taking up for myself or expressing facts. I treat people the way I want to be treated until they show me they want to be treated otherwise.


    Quote from DutchgirlRN
    The day nurse has no business mixing 9am and 11am meds. The latest the 9am meds should be given in 9:30 and the earliest the 11am meds should be given is 10:30 so I don't see her motive unless it's laziness. Goodness, only one patient to care for. I have done private duty with trached patients with loads of meds and I never had trouble giving meds on time. But it is hearsay...no complaint against you.
    It's irrelevant whether or not she should be mixing medications. This relative has not been appointed as supervisor of this nurse (no, this nurse is not me. I know this nurse and she is a very good person and hard worker who has put up with A LOT from this family, and I believe her when she said she did not mix any medications. I'm not going to criticize her for how she chooses to do something.) This relative had no right to assume role of superior to this nurse and reprimand her, especially in front of others, and having met this devil personally I get so angry thinking about it I wish I could write to someone who would reprimand HER for this behavior. If anyone needs and attitude adjustment it is this niece. And I know when I feel this way I am dealing with a bad apple, because I can get along with almost anybody but this person sends shivers down my spine.


    Quote from DutchgirlRN
    The family has no business looking through the chart. There's no reason why they can't simply ask the nurse on duty how the patient is doing. Is the patient orientated? Just curious...she should have a say in this
    But that's the issue, and it isn't even the family looking through the chart. It's the niece who just moved here from another part of the country. Yes, she is a DON but she is not a DON with the company we work for. This woman has 12 children and numerous grandchildren and great-grandchildren who are MARVELOUS! Then, here comes this niece who has become a self-appointed charge nurse of the house...she doesn't come by all that often but when she does she makes sure everyone knows about it and leaves grief in her wake. She is a rotten human and I'm not about to apologize for feeling as harshly toward her as she wants to be toward others.
    By the way, there was never an issue with family going through charts until this niece came into the picture a few months ago.
    Furthermore, the patient is oriented enough to answer questions appropriatelty and carry on a coherent conversation, however, she makes poor judgements (turning on a stove and putting her hand on it to see how hot it is) and displays obsessive compulsive behavior (folding and refolding towels and sheets time and again). She also has extremely poor short-term memory (we constantly have to remind her yes, she has taken her medication).

    Since we are talking about reprimanding, isn't there someone this niece could be reported to? I'm not a vindictive person but I do believe she does need to be reprimanded. There may be no case, but it seems she has broken laws herself by using her position (I'm a nurse) to muscle her way around the home and take it upon herself to comb through the patient's chart and constantly belittle and question the nurses about what they are doing.

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