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

[All4NursingRN]

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?

[stefanyjoy]

Oh, dear.

I feel that institutional covered entitites rush their HIPAA training so quickly that it basically says "PHI PEOPLE! DISCLOSE IT AND BE FIRED! NEVER BREATHE A WORD!"

Keep your list, with patient names and whatever else, in a LOCKED location at work that only you have access to.. basically, got a locker? Your individual facility determines if PHI is allowed off the premises, not the government. However you are responsible for proper disposal of the information should you choose. It needs to be shredded, burned, whatever.

If for whatever reason your locker is to be broken into one day and someone steals your list, or it magically combusts and your notebook sails out into full view, report it immediately.

I work in health insurance. Claims. Medical records. I've got PHI coming out of my youhoo. I WORK AT HOME! AWAY FROM THE OFFICE! Everybody gasp.

Don't mean to sound like a you-know-what. I'm the throes of cymbalta withdrawal. stupid drug.

[nurseprnRN, BSN, RN]

like stephanyjoy, i have many medical records come through my home office. we are under the same hipaa restraints as anyone else; we are allowed to have them in our possession to perform normal job functions, and we are also held to the confidentiality duty standard.

when i am done with mine, they get shredded (in the summer) or burned in the woodstove (in the winter)(might as well get some heat out of them). i do not leave them lying around where anyone can find them. my secretary also works at home and sometimes gets a pile of them from me to scan and put on disk for long-term storage. she has been thoroughly educated in hipaa; when she is done with them they go to a commercial confidential-records shredding service.

i think the concept is to be careful with them. have and consistently follow established policies and procedures for handling any phi, including any notes or analyses you might do. then when somebody asks you, you have a good answer that demonstrates your awareness and practices.

[AnonRNC]

Your individual facility determines if PHI is allowed off the premises, not the government.

Make SURE you know your facility's policy!

[HazeKomp, BSN, RN]

#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.

[bradleau]

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.

[Flare, ASN, BSN]

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.

[DSkelton711]

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.

[Reese0608]

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

[owlRN01]

Tagging this for future reference :)

[Jory, MSN, APRN, CNM]

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.

[Esme12, ASN, BSN, RN]

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.

[nurse2033, MSN, RN]

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.