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

Eaglelady · Mar 14, 2012

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 · Mar 14, 2012

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?

Pinkmegan · Mar 14, 2012

We have printed sheets of all patients, room numbers, age, manual handling instructions, dietary reqs., etc. to use for notes at handover, & to help agency nurses. At end of shift they ALL go in the shredder!

This info is for us & us only as an aid mémoire thro the day! The patients notes should then have all the info u need & which will be the document used, hopefully never, in court!! Keep it succinct but keep it accurate with times etc.. Believe me u don't want to go there!

teddycat1962 · Mar 14, 2012

I think it's a good idea, as long as it didn't have the pt's full name and other PHI on it. Just be careful about leaving it around. In other words, guard that info with your life. If, for some reason, you were called into court the "I don't recall" response is always good. :)

Wishinonastar, BSN · Mar 14, 2012

For many years I kept a notebook with notes on home health patients- it helped me chart and to look back at things when a question came up. With HIPAA we are not allowed to do this. I was always taught that you can keep a memory jogger as long as no patient identifiable info was on it, but this is for your eyes only. The thing is, without a name on there how would you ever know a week later who the patient was? No, I now destroy my notes after the day is over to avoid problems and just trust my documentation. Be safe. Destroy what you have and don't do it anymore.

NicuGal, MSN, RN · Mar 14, 2012

If you work in peds or OB/NICU, the limit of statue is 18 years plus. The parents have until the age of 18 to bring suit, then if the the child is competent, they can sue after the age of 18 for say a scar or whatever, even if the parent thought it was no big deal. I just was involved in a case in which the child is now 22year old. They brought suit when he was 18 and it was 4 years after that for it to go to court. So, if you think a report sheet with no identifiers on it is going to help you, it won't. Can you remember anything from 22 years ago...thank goodness we had good charting.

If you disclose you have ANY information on the patient, you will be asked to produce it and it could be admissible, esp if there is anything to identify a certain patient. They also pulled our staffing sheets from the time that the infant was in our care and determined who was in charge, etc. It is quite a process,not one that I would wish on anyone.

finallyfound10 · Mar 15, 2012

If the facility has a policy- it needs to be followed. Nothing the lockers then nothing in the lockers. HOWEVER.....we hear all of the time in this litigious society to "document, document, document" in order to protect ourselves and there could be situations where the chart is not at all appropriate to document something but it still needs to be written down "just in case" and/or CYA. I think that it is a gray area in a lot of situations.

Chaya, ASN, RN · Mar 15, 2012

Def a gray area. In school we had a journal of the patients we cared for which we turned in weekly to the instructor. Pts were identified only by initials, age and gender, ie: E.F., 79 year old female. Not too difficult to ID if condition, labs and assessment taken into account, but technically, non-identifying. We took our worksheets home to journal and we also wrote a note in the pt's chart which did not leave the floor.

At work pt worksheets were kept in my locked locker in a locked staff room until the patient was discharged b/c if I had the pt more than once the previous worksheet would frequently provide some small detail to jog my memory, especially if I had not had them for a couple of days. I wrote fairly thorough chart notes but if you recorded everything each shift note would be about a full page long and take 20 min to write (X 5 or so pts!). Policy was in general to chart by exception but specifically address the pt's primary complaint; specific assessment, vital signs, I's and O's etc were recorded in other areas of the chart so were not needed in the shift note. Also-in the interest of brevity report from the off-going RN tends to cover only the main events and may leave out events of the previous 3-4 days.

On occasion I was asked about specific situation after a pt had been discharged. You were called into the manager's office and asked about someone you cared for a week or 10 days before. They might have a copy of the chart note there but usually didn't have the other data sheets so you could say "As I recall..." or you could say "I need to see the assessment" and either way you were made to feel like an idiot. So- If I did have a situation that I felt might become an issue I would bring home an initials-only version of my worksheet or even an initials-only version of my narrative note in case it went further. So far haven't needed these but have on occasion referred to the worksheet in my locker for specifics. Could be risky, I know, but in these cases the main objective seemed to be info and not someone to blame...

Professor_Mike · Mar 15, 2012

Not even addressing the HIPAA issues, which may be very serious, but the existence of personal notes outside of the medical record are admissible in court and you will be asked very early in any deposition if you have any such records. Anything other than the truth is perjury. Guilty of perjury means prison time! If one of your co-workers who happens to be called to testify in the same case is asked if they or any other defendant has personal notes that they are aware of and let's the cat out of the bag, one of you is not telling the truth. Bottom line is don't keep any records, the potential problems far outweigh the benefits.

Pinkmegan · Mar 15, 2012

. I wrote fairly thorough chart notes but if you recorded everything each shift note would be about a full page long and take 20 min to write (X 5 or so pts!). .
5 or so pts??!! I can have up to 16 so need as much help as I can get to remember!!

Eaglelady · Mar 15, 2012

I agree I can have up to 20 patients so I totally understand thats why I have my notes but still at the end of the day everything I have on me ended up always in the chart so my notes are duplicated to the chart:hrnsmlys:

Wickeddiaz · Mar 16, 2012

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 back it up and say yes or no i had this patient or this pt was discharged or admitted at this time.Is this good or bad practice?One nurse told me it's not good practice because she had recent court cases to go to and they ask if you keep a written record of your patients and she said no and to never say yes.What do you think?

It is one thing to keep old report sheets at work in a locker. If you take them home or write notes in a diary format that can be problematic. A lawyer can pull all of your notes into litigation and depending on what type of information you have kept on a patient it can paint your care for that patient in a poor light. For example if you wrote negative statements in a manner of just needing to "get it out" on paper that can be held against you. If you made reference to incorrect care, or if your notes go against the grain of the charting on the chart that can make a nurse look like he/she did not know what was going on.I love the practice of refelcting through notes but I incourage my nurses and my nursing students to do this in a verbal debriefing format in a safe area. That way information can be shared and challenging situations discussed without the fear of being overheard or having the paper trail discovered later.Kris