patient family and nursing documentation

[shilohmae]

With patient permission, family members can look at nursing documentation anytime-correct?

Thanks for the information.

[mairehRN]

For Pt. records to be reviewed by a family member, they should be listed as next of kin, the patient listed who they want notified of their health and any issues at the time of admission. The social worker and DON or the units PCC/manager, sit down with them and go over what everything means. They can then get a copy within a set amount of time per facility policy, from the Med. Records dept. for free or with a set fee.

[withasmilelpn]

I was taken aback by your question and have edited my response. The legal nature of nursing documentation and all other parts of a patient's medical record is generally well-covered in nursing school curricula.

However, I answered your question as it was asked. Yes, it is lawful for pts. to be provided w/their medical records. But your question, as I understood it, meant something different - handing over a patient chart "anytime." While probably not unlawful, that practice will most likely violate the policies of most facilities.

I am glad that you ammended your response. Just try in the future to remember that this site is helpful because it can provide answers to questions we have, no matter how seemingly small. We were bombarded with information as students, no way to remember all of it. Skills you learned years ago fade when you don't use them-don't use it you lose it!

I love this site just for the fact that I can say what I think without worrying about appearing stupid or too negative, etc..., don't you?

[caliotter3]

I don't recall this topic being covered in my nrsg school. I work in home health. The field chart is avail to the pt and members of the family. At one case, I was told by one of the other nurses that charting was done in a particular manner on purpose b/c the primary nurse copied the charting for the family. They had already engaged in at least one lawsuit. There are ways to deal with this, but it just reminds the caregiver that you must be very aware of your charting.