Keeping A Written Record Of The Patients You've Had: Good Or Bad? Keeping A Written Record Of The Patients You've Had: Good Or Bad? - pg.4 | allnurses

Keeping A Written Record Of The Patients You've Had: Good Or Bad? - page 4

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  HazeKomp profile page
    #39 1
    #1 any notes/journals/papers you may have at home or in a locker will be called in as evidence! Period.
    #2 any notes/journals/papers you may have at home or in a locker are indeed a HIPPA violation. Period.
    #3 denying the existence of such notes would be perjury, jail-time... let alone unethical!
    #4 most likely against hospital policy and you could loose your job if they find out....
    could also be against your state's Board of Nursing regulations and you could loose your license!


    So............
    two suggestions:
    #1: become a charting professional, putting details into your notes and charting!
    Remember, not charted=not done.
    Also, most cases do NOT come to court for many years, hundreds of patients later!
    #2: IF you DO indeed have a special case, situation that you are concerned will come to court in later years,
    put the "special" documentation into your hospital system's occurrence/incident reporting system!
    The hospital can legally keep the info for reference and you are remaining professional, ethical.
    ex. the litiginous patient who keeps threatening to sue everyone
    ex. non-chartable information about sentinel events like low staffing,
    missing equipment, poor response times from support crews, etc.
    ex. doctor problems like "don't tell the patient but I'm not ordering that because I think it is a waste of money on them"
    "I have a hot date, so don't let her deliver the baby between 6pm and 10pm"

    I am known for my detailed charting... it has come in VERY handy on several court depositions!

    I am known as the "Occurrence Report Queen" because I insist on patient safety and quality care! If someone or something puts MY patients in jeopardy, I'm reporting it! Examples: frayed cords engineering are slow to fix; unsafe staffing levels; doctors who are either unsafe or just stupid, etc

    Do not keep notes at home.
  2. Visit  bradleau profile page
    #40 0
    Our facility keeps all electronic signatures in charting, medication administration. Sometimes I keep my assignment sheets especially when I am charge. That way I would have at hand the names ofall my patients on the unit. In the nearly 20 yrs that I worked at this one hospital, I have been called in to talk with a lawyer about certain patients twice, In one case, I had taken care of this person several times over a few years so was I was familiar with him.. That legal issue had occured upon discharge/ days. Not my shift though all were questioned. The second patient was years later. In that case all I had done was witness the PCA medication. Two signatures were needed. So that is how I got involved. I had kept my floor assignment list here at home for some unknown reason at that time, so I did at least have something. ( the lawyer who discussed this patient with me, filled me in about various lawsuits that had been filed). That was the year that I was not working due to major health issues of my own. Seeing that name on my worksheet refreshed my memory. I have not had to testify or give a deposition. Our floor charge nurse on days saved every worksheet.. who she assigned to what patient, doctor calls, etc. She is now retired. Talk about a pile of papers in her locker and on top of it. SO one never really knows when you may be called for a talk with the hospitals lawyer.
    Last edit by bradleau on Mar 19, '12 : Reason: further information
  3. Visit  Flare profile page
    #41 2
    If you cared for the patient, then chart on that patient. That should be all the evidence you need for administrators that you did or did not have a hand in caring for a patient.
  4. Visit  DSkelton711 profile page
    #42 0
    IMHO I would not do it. It could backfire in so many ways. I think the ANA website has a person who can answer your question best.
  5. Visit  Reese0608 profile page
    #43 0
    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!"

    The 'journal' is pretty good idea too, but it cannot take the place of thorough charting.
    that was how we were taught to chart in nursing school always back your actions or not doing something up
  6. Visit  owlRN01 profile page
    #44 0
    Tagging this for future reference
  7. Visit  Jory profile page
    #45 2
    Quote from NicuGal
    You should not be keeping things with patients names, etc on them in your house, that is a huge HIPAA violation. I have been involved in several cases and always have been asked if I have any records in my possession. But, what do you have on your report sheet that wouldn't be in the chart? Hopefully nothing. If in doubt, I'd ask legal what their take is on that. If you have something on your report sheet and it isn't documented on the chart, and the prosecution gets a hold of it, well, that could really open a can of worms. You are better off to say "I don't recall" then you are to try to figure it out from old report sheets...it is bad enough to try to piece things together from a chart! Just my opinion from experience.
    Here is my take on it.

    "I don't recall" isn't going to save your rear if you get unjustly accused and all the evidence lies with the facility.

    You keep a record if important incidents or anything comes up. You also don't tell ANYONE, and I mean nobody, that you keep such information. If some lawyer asks, YOU TELL THEM NO ANYWAY. I would bet you a year's salary that no judge can force you to produce what nobody knows even exists.

    Am I OK with lying? You bet your bottom dollar I am, because at the end of the day, the only person that is truly going to be on your side is YOU.

    I had a relative that was a nurse that died and we found 28 hard-bound journals of an entire career's worth of important events. Not even her own family knew she had them until they cleaned out her home when she died.

    PS: You cannot use your personal note to back you up in a court case...you use them to simply refresh your memory.
  8. Visit  Esme12 profile page
    #46 2
    Quote from Jory
    Here is my take on it.

    "I don't recall" isn't going to save your rear if you get unjustly accused and all the evidence lies with the facility.

    You keep a record if important incidents or anything comes up. You also don't tell ANYONE, and I mean nobody, that you keep such information. If some lawyer asks, YOU TELL THEM NO ANYWAY. I would bet you a year's salary that no judge can force you to produce what nobody knows even exists.

    Am I OK with lying? You bet your bottom dollar I am, because at the end of the day, the only person that is truly going to be on your side is YOU.

    I had a relative that was a nurse that died and we found 28 hard-bound journals of an entire career's worth of important events. Not even her own family knew she had them until they cleaned out her home when she died.

    PS: You cannot use your personal note to back you up in a court case...you use them to simply refresh your memory.
    You should publish them "with the names changed"....the diary of a nurse.
  9. Visit  nurse2033 profile page
    #47 0
    I can't believe what I'm reading. Keeping PHI in your personal possession is illegal under HIPAA. Once you are no longer caring for a patient, you are no longer involved in their care, which is what gives you the right to access their information in the first place. HIPAA requires the minimum amount of access to PHI in all cases. The example of the nurse who kept records in her attic is a good one. Those records are now armchair reading for her family and many of those patients probably still live in the community. This is not a gray area nor open to interpretation. I would love to hear from anyone who can show a hospital policy that states it is OK for a nurse to keep their own patient records.
  10. Visit  NicuGal profile page
    #48 0
    Jory, I take you have never been deposed or on a case. I won't say much more than I did before, but it is a whole different world when the lawyers are on you. And a jury may see things much different than you do....
  11. Visit  Esme12 profile page
    #49 0
    Keeping a private secret personal journal where the names have been changed to "protect the innocent" when something out the ordinary or abbarent occurs is using your head. Admitting you have one is not using your head. I have been disposed in the past and whne asked if I have any records at home I honestly say no......I do not have nan "records" at home. Do I keep report sheets? No I do not......do I keep a journal? Yes I do.
  12. Visit  somenurse profile page
    #50 0
    I will get slammed, and rightly so, anyone upset with me, i would have no good argument,
    but,
    i always kept my assignment sheets, at my home! for eons. No one knew of it, ever, and after several years, i burned them.

    why did i do this?
    first off, when i first began the habit, HIPAA was not much of a big deal decades ago, not like it is today.

    second off, i have horrible memory, and this did help, if my boss would tell me about remarks on a patient survey, or other 'after care' discussions that came up, when i went home and looked over my notes, it all came back to me. (my memory for names is so dreadful, that i often wrote lil identifiers next to each pt's name, like "big mustache" or "loves dogs" or whatever, to help me bring that pt to mind.) Without my notes, i always felt like idiot, that i could not recall whoever it was being discussed. At the time, i saw this as secretly working around some name-recognition deficit that i have.

    I wouldn't do this NOWadays, but, i used to.

    anyone appalled, i pre-agree, and pre-apologize. You are right.
  13. Visit  SleeepyRN profile page
    #51 0
    I think as long as you keep your records in the building its ok. Like in a locker, absolutely nowhere where it could be stumbled upon, though to be viewed by others eyes.

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