Keeping A Written Record Of The Patients You've Had: Good Or Bad? - page 5
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
Feb 3, '13 by nurseprnRNQuote from ChayaTotally not a grey area.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...
If anyone asks you about a specific situation you have nothing to lose at all by saying, "I can't remember from just this piece of charting you're showing me, I would need to see the rest of my charting." Nobody can make you feel stupid without your consent. It doesn't matter what the manager in the office asks you or thinks of you. I'll tellya, if you don't say exactly that on the stand or in deposition, you will be pinned to the wall. That DOES make you look stupid.
If you are asked if you kept any other notes (and believe me, they WILL ask), and you lie, they will ask your coworkers if this was common practice or if they ever observed you to put notes away in your locker or purse. If one says, "Yes, we all did it, Chaya said it was important to help her remember things," not only do you look stupid, you get tapped for perjury.
Do NOT do this under any circumstances. The medical record is a legal document, and therefore it had better have everything in it. The stories I wish I could tell about cases with nurses in serious trouble because of missing or ambiguous documentation would absolutely curl your hair.
Feb 14, '13 by HARLEYDNSHere's the real deal. Keeping your own records is your business. In my opinion a personal journal is better than keeping you work sheets and do not EVER tell anyone you have this. It is for your protection, and your eyes ONLY..... now, how to get around the HIPPA issues, (this is not a hippa violation) ... but for the ones who think it is.... you dont use names in your journal. Only room #'s and initials.
The reason you do not tell ANYONE that you have this journal is because if an attny finds out you have it, it CAN be used in the court of law, and may be used against you.
However, with employers not protecting their nurses any longer you MUST protect your self. Trust me, in 5 years from now are you going to remember the patient that was a diabetic and his blood sugar was 87 after breakfast? HELL, no! However, if you have a PRIVATE journal you will remember it once you get the chance to go home and pull out that SECRET journal and read it. The chart is public info. once it gets into the legal system. (Public as in the courts) They can use your chart notes however, when you go home and write your real thoughts like (he was a jerk, pervert, nice guy, bald....ect.. 10 attempts to get his IV going) you know that stuff, you will then be able to recall the patient better than what your quick note in the chart was. If you can not remember a patient you can just ask when was he a patient there? Then you go to your journal and look up that date or aprox date and you will find it. A court case may not even come up for a year or two, but getting to the official court day may take another year or two, so believe me you will not remember one patient from another a few years down the road unless you keep a journal.
On a good note, you can keep your journal to use when raise time comes, you can flip thru it and remind youself of all the times you went above and beyond the call of duty. Then you remind your boss of those days when raise time comes.
Good luck, and start you "PRIVATE" journal ASAP!
Feb 14, '13 by Nurse_, BSN, RNDe-identification of PHI
Removal of certain identifiers so that the
individual who is subject of the PHI may no
longer be identified
♦ Application of statistical method or
♦ Stripping of listed identifiers such as:
- Geographic subdivisions < state
- All elements of dates
De-identification Standard (45 CFR 164.514, (b)(2), (c))
I do keep my own record, call it a journal. After each shift, I remove the patient's labels (either by marking them or with a privacy sticker). I keep a record because:
- Patients are now aware about nurses' malpractice insurance and are now subject to litigations.
- Hospitals will not protect me in case of a lawsuit. It'll protect itself.
- The BRN had been amazingly kind in suspending or revoking licenses.
Feb 14, '13 by psu_213, BSN, RNQuote from HARLEYDNSWould the blood sugar not be recorded in the chart? It better be. Suppose the blood sugar was 248 and you gave him the appropriate SS insulin. Something happened later on R/T the insulin. You come back several years later and say, "oh no, it was the correct insulin dose...he had a blood sugar of 248." So the lawyer asks "how do you remember that figure from six years ago?" "Oh, it wrote it in my super secret journal!" Well, now your journal is not so super secret anymore, and now it is could be used against you in a court of law. I don't see how difficult it is to "officially" chart all this stuff in the first place.TTrust me, in 5 years from now are you going to remember the patient that was a diabetic and his blood sugar was 87 after breakfast? HELL, no! However, if you have a PRIVATE journal you will remember it once you get the chance to go home and pull out that SECRET journal and read it.
Feb 15, '13 by HARLEYDNSWow! No you would write in your journal things to remind you of the events that took place that day !!! Again you would never ever say you have a journal...As I said in my first post it is your PRIVATE journal. I totally agree with documenting EVERYTHING, but again in 5-10 yrs it all becomes a blur...so a journal is the way to go. As I said there are things you do not write in the chart but are things to help you recall the events. Ie... he was wonderful, his wife was a drunk and came in drunk....etc... as "[COLOR=#003366]Nurse_ " wrote it is to help you keep protected! After over 20 yrs as an RN, and 20 yrs as a NA and LPN (nursing assist. were not certified back in my day) so total 40 yrs in nursing, the journal is the way to protect yourself as employers no longer back their nurses. It's just about protecting your self and your family! It is not a legal document, and it has no names, its only your reference, call it what you want but again No one EVER knows about your journal. So, obviously when and if ever in court you never say you have a journal..... before getting into court you will have the opportunity to speak with an attorney and you will go over the patients chart with the attorney. You then go home and read your private notes for better recall and tell the attny. I have been thinking about this and I remember....xyz about the patient, it is not play by play of the day with each patient is just a recap of the days events. ie... very busy, guy in rm 2 coded, and went to ICU..etc.. I had 8 patients and 3 admits and 2 d/c's etc....just my own personal experience after many years of nursing. That is what makes us a diverse group of people, we all have ways of doing things. Just sharing mine.
Feb 15, '13 by nurseprnRNYou're entitled to your opinion. However, if you are deposed and asked how you are able to remember so much from years ago, it will simply not be credible to say, "Oh, I have such a great memory." There are too many ways to catch you on that. Your attorney will not want to know that you have separate records, because when it comes out (and it will), he will be up for charges himself because he must reveal all relevant materials used in preparing the case to the other side unless they are internal attorney office work product, which your journal would not be. Further, if you keep it in code, you may be hard pressed to prove that it's real anyway.
Can of worms waaaay too big. You do what you want, but seriously, good charting will save your butt more than your supersecret diary with the little lock on it.
Feb 16, '13 by psu_213, BSN, RNQuote from GrnTeaI was thinking this too....you are suddenly going to go into court, a deposition, etc. and bring up all these facts that are not in the chart and try to attribute it to your memory? So then it is revealed you had a journal. Now this can go two ways: First, you kept at home a record of you patients with names and ages...big time HIPAA problems there. Or, you refer to them only by initials. A lawyer would say, "how can you be sure that this in the only pt you has with initials MW during this time? How can you prove that you are talking about Mary Williams and not Michael Wallace?"it will simply not be credible to say, "Oh, I have such a great memory."
Also, now you would have to make your journal public. How are all those little clues that you wrote about the patients going to look? It may jog your memory, but it will cast you in a really bad light when it is revealed you wrote a note that says "a 45 year old balding overweight man who is rude and makes crude sexual comments."
Feb 16, '13 by kakamegamamaOP--you mentioned a nurse told you that she said "no" when asked if she had other records? If the answer should have been "yes", lying on the stand or during a deposition can get one into tons of trouble, to put it mildly. No need to keep an ongoing record----there should be evidence in the chart that you cared for that patient. And, anything that you have recordwise is something that can be subpoened if a malpractice case should come up.
Feb 16, '13 by chrisrn24Quote from GrnTeaI'm inclined to agree with this.You're entitled to your opinion. However, if you are deposed and asked how you are able to remember so much from years ago, it will simply not be credible to say, "Oh, I have such a great memory." There are too many ways to catch you on that. Your attorney will not want to know that you have separate records, because when it comes out (and it will), he will be up for charges himself because he must reveal all relevant materials used in preparing the case to the other side unless they are internal attorney office work product, which your journal would not be. Further, if you keep it in code, you may be hard pressed to prove that it's real anyway.
Can of worms waaaay too big. You do what you want, but seriously, good charting will save your butt more than your supersecret diary with the little lock on it.
Feb 22, '13 by NicuGal, MSN, RNYou are better off saying I don't recall. If you go home and look something up and say something on the stand that has not been discussed with your hospital legal team you will be in the hottest water you ever stepped into. Especially if something is not in the chart. The legal team shows you what they want you to see and know. Best off to just go with the flow the legal team sets.
Feb 22, '13 by dthfytr, ADN, LPN, LVN, RN, EMT-B, EMT-IWhat we seem to be discussing is anecdotal records. They are very, very powerful in court! Some people keep them, I don't. I don't remember squat about identifying a patient, and it would be terribly wrong of me to try. I might confuse patients, give wrong information, and end up in deep yogurt. If involved in a legal action, I remember nothing! I will read my nursing notes, and explain as needed. Reading and interpreting another person's notes? Nope, not never no how! Electronic charting will be interesting. I've seen probably a half dozen legal actions brought against healthcare in some way. Every time, part or all of the written record has vanished like one sock in every load of laundry, or airline luggage. It will be hard to erase electronic charting.
Mar 12, '13 by Jory, ADN, BSN, MSNHere is the reality of it...if you keep these records at home, you don't tell ANYONE about it, ever. Not even your most trusted co-workers or friends, nobody.
Many "old school" nurses have always kept this documentation because we all know that there are some things that you cannot chart. No, it is not admissible in court and yes, I would ABSOLUTELY lie about having it in my possession, because if nobody knows but you, then nobody knows...but it can help you recall facts, etc. that may have been in appropriate to write in the chart.
Ben Franklin said that two people can keep a secret...and one of them is dead.
Apr 22, '13 by calivianya, BSN, RN ProThis is a really fine line. I have been doing my last clinical of nursing school in a MICU, and all of the nurses keep notes for report. Why? The report is insane on patients in the MICU. The nurses seriously want to know everything that's happened to a patient since admission, so if you're reporting off to a nurse who hasn't had the patient before and the patient's been in the hospital three weeks, well... report may take twenty minutes on just that one patient. The only way to keep the patient straight is to keep notes on any patients you've had. The notes are definitely the same as would be in the chart, but it's really impractical to dig through the patient's entire medical record every single day before shift change to read off the medical record when you could have a written history of the patient's hospital stay in front of you. On a patient I've never had before, I may spend 45 minutes preparing for report in the morning, and my nurse says that's not uncommon. It usually takes her at least half an hour to prepare if the patient is new to her.
Lately, my preceptor's been having me do report. Does this mean I have sheets with very identifiable patient information in my clipboard currently on my desk at home that I take with me to clinical, since I'm a student and don't have a locker on the unit? Well, I'm not going to say directly, but you can guess the answer there. I personally won't throw anything away until the patient's been transferred off the unit, so I know for sure I will never have to give report on the patient again, but then again, that fails for me sometimes if a patient gets transferred off the unit but ends up needing pressors and comes right back a few days later. I should probably throw my notes away, legally speaking, but if I did throw my notes away every day I'd spend hours looking them up again every shift, and taking that much time away from patient care to get ready for report is not really acceptable either.