Keeping A Written Record Of The Patients You've Had: Good Or Bad? - pg.2 | allnurses

Keeping A Written Record Of The Patients You've Had: Good Or Bad? - page 2

I've always kept my paper list of patients I have when I take report and thoughout the shift of the patients I've had. Now I keep a notebook just in case management pulls me in for questioning I can... Read More

  1. Visit  psu_213 profile page
    6
    I'm still a fan of charting basically everything even if it seems mundane.

    ER example: pt reports 10/10 pain, doc orders pain meds, pt says "no, I'm fine, I don't want anything. Even after explaining the benefits of pain meds, etc, the pt still refuses I will chart that. If they turn in a survey and say 'they did nothing for my pain,' it is there clear as day that I offered pain meds and they flat out refused.

    Another example of what I would chart: "pt requested food, told pt that since diagnostic tests were not complete yet, they are unable to eat at present," for a case where a pt says "I sat there for 2 hours and the made me starve!"

    The 'journal' is pretty good idea too, but it cannot take the place of thorough charting.
  2. Visit  CapeCodMermaid profile page
    9
    If you can take the time to write something on a report sheet, you should take the time to document it in the patient's medical record. "Wait, your honor! I didn't write it in the chart,but I kept separate notes on a piece of paper."...I don't think so.
  3. Visit  MyMystudentRN profile page
    4
    Quote from psu_213
    I'm still a fan of charting basically everything even if it seems mundane.

    ER example: pt reports 10/10 pain, doc orders pain meds, pt says "no, I'm fine, I don't want anything. Even after explaining the benefits of pain meds, etc, the pt still refuses I will chart that. If they turn in a survey and say 'they did nothing for my pain,' it is there clear as day that I offered pain meds and they flat out refused.

    Another example of what I would chart: "pt requested food, told pt that since diagnostic tests were not complete yet, they are unable to eat at present," for a case where a pt says "I sat there for 2 hours and the made me starve!"

    This is exactly how i chart and will continue to chart!
  4. Visit  AnonRNC profile page
    3
    Quote from All4NursingRN
    My reasoning for keeping it wasn't really for legality, but moreso for administration. Plenty of times managers have approached nurses about something that wasn't done for x,y,z patient and sometimes the patient wasn't theirs, or the action or misaction in question had or hadn't been performed. I use it moreso to keep track of what time a patient was transfered from my care, etc.. In fact my co-workers and I have used it as proof of unsafe staffing to show how many patient's we all had within an period of time.

    Sometimes management approaches us for information on a patient we had weeks ago, and whether this or that was done or not. If this or that was charted, sometimes the patient was transfered from your care hours ago or something they are asking about when the patient wasn't even assigned to you as yet (i.e previous shift)

    But like some of you said I do think it maybe a HIPAA violation.
    I see now what you're getting at. Here's a better way to handle it: Write a narrative note for every patient you care for. Include in your note "Assumed care of pt at 0730 after receiving SBAR handoff from M. Smith, RN. Pt alert, oriented....etc..... SBAR hand off to S. Jones, RN at 1315." If management comes to you, you just have to go to the chart to see if you were caring for the patient at that time.

    Regarding staffing concerns: you can keep records but there is NO need for names. Your sheet might just be a table or chart with headings across the top that are relative to acutiy in your practice area. Then one line for each patient. I work in the NICU and mine might look like this (only formatted in columns).

    3/12/2012
    Patient - Resp support - IV - Other - Time in care
    #1 - Vent - PICC x2 - unstable ABGs, transfused - 0700 to1930
    #2 - Vent - PICC & art line - stable ABGs -700 to 1700
    #3 - none - none - feeder/grower - 1500 to 1930

    And I would just use "Pt #1" etc. No names! Depending on your practice area, your headings might be different, such as if the patient is disoriented & climbing out of bed, on hourly neuro checks or frequent assessments for restraints or whatever it is that ups acuity/nursing burden for you.
    Last edit by AnonRNC on Mar 13, '12 : Reason: Added times pt was in "my" care
    PrayeRNurse, MinnieMomRN, and Eaglelady like this.
  5. Visit  GrnTea profile page
    0
    ok, and then when that attorney asks you to support your assertions about your care of the day in question, you say, "yep, got it right here." and he says... how do we know that's the patient in question? and if you tell him you know it is, then you are asked to prove it, and before you know it, you are disqualified as a witness.
  6. Visit  Eaglelady profile page
    0
    Well I have kept my notes for years but whatever is in my notes is in the chart but also note things that are passed on and when the next shift nurse states I never passed it on I can show I did but I also keep my records under wrap where no one can see it but I do not keep any info on it that can identify the patient just room numbers and dates with any tx I did or meds I gave or labs I drew , etc ---but I see nothing wrong with it and I am a supervisor but it is up to the individual as to how they feel but for me I will keep my record as always
  7. Visit  psu_213 profile page
    1
    Quote from grntea
    ok, and then when that attorney asks you to support your assertions about your care of the day in question, you say, "yep, got it right here." and he says... how do we know that's the patient in question? and if you tell him you know it is, then you are asked to prove it, and before you know it, you are disqualified as a witness.
    according to the op, she is not keeping this log for legal reasons. it is absolutely true that your log will get thrown out if you try and say "i wrote this stuff down and kept it in my locker." if it is going to be used in court, it must be on the chart.

    if the op wants to keep a 'list' of pt load and acutity i like the idea of specifially charting times you assumed care of the pt and from whom you got/to whom you gave report. in the end, however, i think it fairly unlikely that management will care how overworked you were and the high acutity was for your patients.
    Eaglelady likes this.
  8. Visit  loriangel14 profile page
    3
    If you have charted properly there should be no reason to keep your notes.We have a shredder.Nothing leaves the floor with us period.It all goes in the shredder.
    enchantmentdis, Flare, and psu_213 like this.
  9. Visit  Whispera profile page
    2
    I agree with the others who said to make sure your charting is complete and accurate. Then there's no reason to keep any other records in your locker or at home.
    enchantmentdis and psu_213 like this.
  10. Visit  Eaglelady profile page
    0
    Well again its a matter of opinion bc I know I over chart everything in my charts but I have for years kept my own records and will continue to do so
  11. Visit  miss longshadow profile page
    2
    I agree with the folks who think this is a bad idea. You would be committing a HIPPA violation. If you need to keep track of items for yourself, consider keeping a notebook with dates and use only patient initials. That way you would not be violating any HIPPA regulations. Jot down any significant happenings. My understanding is that as long as there are no identifying items, you should be safe. This would belong to you, not the hospital.
    I personally do not keep any written documents with information. I feel that my documentation should support me, if not, then I need to improve my documentation skills.
    PrayeRNurse and Gold_SJ like this.
  12. Visit  Eaglelady profile page
    1
    Well as I said previously I myself have not broken any HIPAA violations I know what to use and not use in my notes and as far as my own documentation it is above average always have been but I still keep my own notes but if the OP feels better keeping her notes go for it just do not use names just room numbers and dates I find thats all it takes to jog my memory cause if they need to know who was in that room on that date they can always go back and check the dates and they will line up--my notes are always inline with my documentation and I have friends that had to go to court and if they had not had their notes to fall back on they would have been screwed literally (their words not mine)
    Gold_SJ likes this.
  13. Visit  Gold_SJ profile page
    1
    I was taught never to keep anything that can portray a patient's identity on your person as it violates confidentiality.

    However...

    I also was taught if there was an incident regarding a certain coworker/patient. You can keep a notebook and write eg.

    On the 15th of March 2012, whilst doing an evening shift 1230hrs - 2100hrs. Bed 7 crashed...etc etc... So the situation is documented but if anyone picked it up there is no clarifying information to indentify a patient, ward or workplace.

    Of course we were always told to document well in the progress notes, the number one rule. But the reason for keeping an incident book was more so if you need to go to court so you have a fresh memory of the situation before you, your feelings/assumptions, convo's with coworkers, ambo's and external incidences like another crash happening, workload, etc things you would never put into a client's record as it's inappropriate, to fully show the issue. We were told to also keep it for bullying problems etc.

    I can't say I've ever really needed to do this, So yes and no.

    Never break confidentiality but you can keep a record of notable incidents from what I'm aware as long as it's not indentifying. Time and date is certainly enough to show to a superior that it was 'that' incident if called up on it. They can always pull a chart to double check.

    I think it depends on your training and state law?
    Last edit by Gold_SJ on Nov 24, '12 : Reason: Edit
    VivaLasViejas likes this.


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