patient family and nursing documentation

  1. With patient permission, family members can look at nursing documentation anytime-correct?
    Thanks for the information.
    Last edit by shilohmae on Mar 5, '07 : Reason: enough replies
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  2. 14 Comments

  3. by   Altra
    No. The patient's medical record is a legal document belonging to the facility. Pt. (or person legally designated as power of attorney) can request copy of medical record through whatever procedure the facility has in place, or it can be subpoenaed by a court.
    Last edit by Altra on Mar 5, '07 : Reason: amended response
  4. by   RN4NICU
    No. The medical record is the property of the hospital. Even the patient has to go through the proper channels to review it. Neither patients nor their family members can just review the medical record any time they want.
  5. by   TazziRN
    They can if the doctor has it in his hand and is going through it with the pt and family. Otherwise, no.
  6. by   cardsRN
    i would reccomend that you ask your supervisor to point you in the direction of your facility's policy on that. my facility has a procedure for requesting a copy of the chart from medical records, but they also have a policy about in house chart review by the pt accompanied by a physician. yeah, in my 4 years there i've never seen that one happen... btw previous posters, i am sure there are things you do not know too, the OP was just asking a question.
  7. by   TazziRN
    Quote from cardsRN
    btw previous posters, i am sure there are things you do not know too, the OP was just asking a question.
    There was only one who questioned the OP. The rest of us just answered the question.
  8. by   shilohmae
    Quote from MLOS
    No. The patient's medical record is a legal document belonging to the facility. Pt. (or person legally designated as power of attorney) can request copy of medical record through whatever procedure the facility has in place, or it can be subpoenaed by a court.

    Seriously ... you're an RN (according to your profile) and you're asking this?
    Since your nasty gram, I checked with the New York State Office Of The Professions. It Seems that providing a patient with their records is lawful. I guess we can all learn something today-even you-imagine that!
  9. by   Altra
    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.
  10. by   TachyBrady
    Up until a year or so ago, I thought we needed a doctor's order before allowing a chart to be copied and given to the patient. That was what I was told when I was a new nurse. Wrong! Where I work, a patient is entitled to a copy as long as they sign the consent for release of information.... no approval from the dr is needed. I don't remember this being taught in nursing school but when I started working, it was explained to me that patients and their families can misinterpret lab and test results.... they should be reviewed with and explained by the doctor. That made sense to me.
  11. by   mamason
    I have only worked at 2 facilities in my short career so far. And both places require nursing supervisor to be notified and then legal documents need to be signed before the pt's chart can be handed over to a family member for viewing.
  12. by   Hoozdo
    I have been in the position of being Medical Power of Attorney for my mother a few times. I always try to have the doctor write an order that I am allowed to read the chart. I have never had a problem doing this. I explain to the doctors and nurses that this will save us a LOT of time. I don't have to bother the nurses with questions, I won't have to wait around for Dr rounds to get updates, and I can interpret lab results any test results myself.

    I am not your typical family member though! I can see where the practice could create more problems than it solved if a non-medical family members would start reading charts. With that being said, I am all for medically competent members of the family having access to charts.
  13. by   morte
    the answer will vary from state to state, and evolves over time.....and i would think law would trump facility policy.....
  14. by   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.

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