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

by All4NursingRN 19,818 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


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    If the facility has a policy- it needs to be followed. Nothing the lockers then nothing in the lockers. HOWEVER.....we hear all of the time in this litigious society to "document, document, document" in order to protect ourselves and there could be situations where the chart is not at all appropriate to document something but it still needs to be written down "just in case" and/or CYA. I think that it is a gray area in a lot of situations.
    Gold_SJ and Eaglelady like this.
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    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...
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    Not even addressing the HIPAA issues, which may be very serious, but the existence of personal notes outside of the medical record are admissible in court and you will be asked very early in any deposition if you have any such records. Anything other than the truth is perjury. Guilty of perjury means prison time! If one of your co-workers who happens to be called to testify in the same case is asked if they or any other defendant has personal notes that they are aware of and let's the cat out of the bag, one of you is not telling the truth. Bottom line is don't keep any records, the potential problems far outweigh the benefits.
    GrnTea, NicuGal, and Altra like this.
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    [QUOTE=Chaya;6252456]. 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!). .

    5 or so pts??!! I can have up to 16 so need as much help as I can get to remember!!
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    I agree I can have up to 20 patients so I totally understand thats why I have my notes but still at the end of the day everything I have on me ended up always in the chart so my notes are duplicated to the chart
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    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 is one thing to keep old report sheets at work in a locker. If you take them home or write notes in a diary format that can be problematic. A lawyer can pull all of your notes into litigation and depending on what type of information you have kept on a patient it can paint your care for that patient in a poor light. For example if you wrote negative statements in a manner of just needing to "get it out" on paper that can be held against you. If you made reference to incorrect care, or if your notes go against the grain of the charting on the chart that can make a nurse look like he/she did not know what was going on.I love the practice of refelcting through notes but I incourage my nurses and my nursing students to do this in a verbal debriefing format in a safe area. That way information can be shared and challenging situations discussed without the fear of being overheard or having the paper trail discovered later.Kris
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    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.
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    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.
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    Quote from stefanyjoy

    Your individual facility determines if PHI is allowed off the premises, not the government.
    Make SURE you know your facility's policy!
    Last edit by AnonRNC on Mar 16, '12 : Reason: grammar
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    #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.
    AnonRNC and GrnTea like this.


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