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

  1. 1 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?
  2. Visit  All4NursingRN profile page

    About All4NursingRN

    Joined Aug '10; Posts: 326; Likes: 392.

    66 Comments so far...

  3. Visit  Nursetastic profile page
    1
    I work ICU and I hang on to all of my report sheets. I've never been told it is bad practice. I keep them in my locker and they never leave the hospital. I've never had to go back to one, but they are there just in case.
    All4NursingRN likes this.
  4. Visit  KelRN215 profile page
    2
    I do not keep my report sheets though I do remember that when I was on orientation, someone in staff development shared a story in which a colleague had kept all of hers and it ended up being useful when she was summoned to court in a certain case.

    My facility holds on to assignment sheets for a while so they have a record of who had what patient and if I've cared for a patient, admitted them or discharged them, they have record of that in my documentation.
    eCCU and All4NursingRN like this.
  5. Visit  NicuGal profile page
    12
    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.
    Janey496, twinkletoes53, scottrho, and 9 others like this.
  6. Visit  AnonRNC profile page
    12
    My facility has specifically said that we cannot keep pt info (report sheets that contain PHI - Private Health Information - but are not a part of the medical record) in our lockers. If you are ever questioned about a patient or a scenario, your documentation in the chart (paper or electronic) is your "go to." We all learned: if it wasn't documented, it wasn't done. If you don't remember (or even if you do), you tell the nice lawyer, "I don't recall; let's look at the documentation."
  7. Visit  OCNRN63 profile page
    3
    Quote from 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?
    It's going to be impractical if you plan on staying in nursing for a long time, and as you've been previously told, it could be used against you if you're involved in a case and the atty. asks you if you have private records.
    xoemmylouox, GrnTea, and Altra like this.
  8. Visit  GrnTea profile page
    10
    and when that atty does ask if you have private records, you are in deep doo-doo, because it is, as stated above, a hipaa violation to have phi in your possession out of work. what if someone else found it, wherever it was? the case for which you are testifying or being deposed has just lost a huge point, because you, as a witness, are discredited. if you are the defendant, worse for you.
    cases of malpractice or neglect do not get brought and heard within days or weeks, unlike on tv. your documentation should always be so complete that you can look at it years later and know what you saw and did. i see cases all the time that are 3-10 years old, and i gotta tellya, a lot of that documentation is really bad. i would hate to have to defend it in court.
  9. Visit  classicdame profile page
    1
    your notes would probably not be admissable in court and there is always the chance you have violated HIPAA if someone else finds your notes. The safest thing to do is to CHART in such a manner that you have a reasonable recall about the patient. Also, keeping notes might indicate you are trying to cover up. Just document appropriately and quit worrying.
    AnonRNC likes this.
  10. Visit  psu_213 profile page
    0
    I guess I can't see any harm if you keep a list of your previous pt's (or a report sheet, etc) in your locker at work, but I'm not sure that I see the point. First, why would your have some sort of 'case cracking' information on an informal report sheet and not the chart? Also, even if you did have some piece of important info on your 'personal' report sheet, it is not going to be allowed in court over what is or is not in the chart. Finally, the way I figure it, if the chart does not jog my memory on the details of the case, then whatever I kept on a report sheet is not going to help either.
  11. Visit  All4NursingRN profile page
    1
    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.
    GrnTea likes this.
  12. Visit  Esme12 profile page
    5
    You shouldn't be keeping patients information and names and they can never leave the premises. It is a HIPAA violation. For me I have always gone home and jotted down the day, like a "journal" I guess, without names, and any outstanding odd occurrences that would jog my memory in the event I have needed it.

    Have I ever needed it? No. Has "journaling" kept me sane with all the really bad things I have seen in my career? Yes. Is it a "record"? NO....not really. Did I use any identifiers? NO Would some nurses disapprove of this practice? Probably. Do I have them still? No....I burn them after "statues of limitations" run out. When I worked would I admit I "journaled" when I got home to decompress? NO. Do I wish I could publish them if I had them and make millions? YUP....there were some amazing and funny stories. "True Confessions of an Everyday Nurse"

    Deciding to keep book on your day is a personal one and a fine line between right and wrong. It a decision you should keep to yourself and yes your charting should be enough to "jog" your memory.
    somenurse, Gold_SJ, GrnTea, and 2 others like this.
  13. Visit  VivaLasViejas profile page
    4
    Agree with Esme. I've done the same thing a few times when patients and/or families have had issues with their care, on the off-chance of being named as a defendant or co-defendant in a lawsuit. It's never happened yet, thank God, but these things can and do happen to even the best of nurses, and over time details tend to fade into the background. So I kept notes, never using identifiers (I used a symbol of some kind, like an asterisk or a # sign), and locked them in our safe at home along with the important papers. Generally, I shred them after a few years go by....don't know what the statute of limitations is exactly, but I figure I'm safe if 5-7 years have passed and I've heard nothing.

    But I would never in a million years take home my 'brains', e.g. a piece of paper with patients' names and info on it, this is a huge HIPAA violation.
    PrayeRNurse, Gold_SJ, GrnTea, and 1 other like this.
  14. Visit  msbloggs profile page
    0
    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

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