Keeping A Written Record Of The Patients You've Had: Good Or Bad? - page 3

by All4NursingRN

19,184 Views | 66 Comments

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... Read More


  1. 3
    If you have charted properly there should be no reason to keep your notes.We have a shredder.Nothing leaves the floor with us period.It all goes in the shredder.
    enchantmentdis, Flare, and psu_213 like this.
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    I agree with the others who said to make sure your charting is complete and accurate. Then there's no reason to keep any other records in your locker or at home.
    enchantmentdis and psu_213 like this.
  3. 0
    Well again its a matter of opinion bc I know I over chart everything in my charts but I have for years kept my own records and will continue to do so
  4. 2
    I agree with the folks who think this is a bad idea. You would be committing a HIPPA violation. If you need to keep track of items for yourself, consider keeping a notebook with dates and use only patient initials. That way you would not be violating any HIPPA regulations. Jot down any significant happenings. My understanding is that as long as there are no identifying items, you should be safe. This would belong to you, not the hospital.
    I personally do not keep any written documents with information. I feel that my documentation should support me, if not, then I need to improve my documentation skills.
    PrayeRNurse and Gold_SJ like this.
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    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 likes this.
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    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?
    Last edit by Gold_SJ on Nov 24, '12 : Reason: Edit
    VivaLasViejas likes this.
  7. 2
    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!
    whichone'spink and loriangel14 like this.
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    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.
    Gold_SJ likes this.
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    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.
    GrnTea likes this.
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    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.


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