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

msbloggs · Mar 13, 2012

definately seen as bad practice! one thing being emphasized as a student is patient confidentiality. bins are provided for any hand written notes through out the day. agree with esme though...if ya want to keep a journal at home, as long as no patient notes have left the hospital and nothing in your writing to identify them thats ok- im a student and find it helpful for learning. As for legal issues - sure your word wont say as much as whats recorded in the legal documentation, unfortunately...thats what im being taught anyway

psu_213, BSN, RN · Mar 13, 2012

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.

CapeCodMermaid, RN · Mar 13, 2012

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.

MyMystudentRN · Mar 13, 2012

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!

AnonRNC · Mar 14, 2012

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.

nurseprnRN, BSN, RN · Mar 14, 2012

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.

Eaglelady · Mar 14, 2012

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 :)

psu_213, BSN, RN · Mar 14, 2012

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.

loriangel14, RN · Mar 14, 2012

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.

Whispera, MSN, RN · Mar 14, 2012

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.

Eaglelady · Mar 14, 2012

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

miss longshadow · Mar 14, 2012

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.