How can I keep tracked of my patients without violating HIPAA?

Nurses HIPAA

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I'm a nursing student and I'm worried about violating HIPAA. During clinical, I keep a sheet going with info on all my patients. How can I know which patient is which on that sheet without violating their privacy? (initials? Room number?) If I put their names down then lost the sheet... major violation!

Also, if I'm working on a case study to turn in to my instructor, how can I refer to my patient?

Any citations/websites/URLs to answers would be very helpful!

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

When taking personal notes on these patients, a first and last initial to identify them should be more than sufficient.

When submitting assignments while in school, I always used the patients' initials to protect their privacy.

And there's always the good idea of DON'T LOSE YOUR SHEET.

It's just good practice. When you're a nurse, the thing that will ruin your day faster than anything? Losing your sheet.

Nursing schools have so many students unnecessarily freaked out about HIPAA and to be honest...many nursing instructors don't even know how HIPAA works or what constitutes a violation.

For example, even in major published studies, using a patient's initials have LONG been used But I had a couple of instructors that not only wanted us to reverse the initials, but to use the next letter in the alphabet for each one...that is ridiculous and even if you used the real initials, that in no way violates HIPAA.

Education of healthcare professionals is an exception in HIPAA, so some latitude is permitted.

Common sense, rules here. It's not hard. You don't access patient's information unless you have been assigned to the patient, you are helping care for the patient or you have access for an assignment. When you turn in information, you use the patient's initials but can use everything else because YOU ARE IN SCHOOL. Of course, an uneducated instructor may have you change more details, but once you get into higher education, you'll find out that isn't necessary.

When keeping sheets to make notes for assignments (very small notebook is better) use the initials but write down one fact that you can remember. Such as, "He said he really liked race cars as a kid," anything to help you remember.

rule # one: don't lose the sheet/notebook.

rule # two: see rule # one.

(those in southern new england will get the reference, lol)

oops, forgot my actual point. POCKETS, use them.

Specializes in Cardiology, critical care, hospice, CCM.
Nursing schools have so many students unnecessarily freaked out about HIPAA and to be honest...many nursing instructors don't even know how HIPAA works or what constitutes a violation.

For example, even in major published studies, using a patient's initials have LONG been used But I had a couple of instructors that not only wanted us to reverse the initials, but to use the next letter in the alphabet for each one...that is ridiculous and even if you used the real initials, that in no way violates HIPAA.

Education of healthcare professionals is an exception in HIPAA, so some latitude is permitted.

Common sense, rules here. It's not hard. You don't access patient's information unless you have been assigned to the patient, you are helping care for the patient or you have access for an assignment. When you turn in information, you use the patient's initials but can use everything else because YOU ARE IN SCHOOL. Of course, an uneducated instructor may have you change more details, but once you get into higher education, you'll find out that isn't necessary.

When keeping sheets to make notes for assignments (very small notebook is better) use the initials but write down one fact that you can remember. Such as, "He said he really liked race cars as a kid," anything to help you remember.

This is very good advice. Remember, to stay organized and keep yourself focused on the task at hand. If you are freaked out about HIPAA all the time, there is no way you can effectively care for your patient.

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