Keeping A Written Record Of The Patients You've Had: Good Or Bad? - page 5

by 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... Read More


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    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.
    Last edit by bradleau on Mar 19, '12 : Reason: further information
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    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.
    enchantmentdis and psu_213 like this.
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    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.
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    Quote from psu_213
    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
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    Tagging this for future reference
    GrnTea likes this.
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    Quote from NicuGal
    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 and 808DIVA like this.
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    Quote from Jory
    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.
    psu_213 and Jory like this.
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    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.
    GrnTea likes this.
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    Jory, I take you have never been deposed or on a case. I won't say much more than I did before, but it is a whole different world when the lawyers are on you. And a jury may see things much different than you do....
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    Keeping a private secret personal journal where the names have been changed to "protect the innocent" when something out the ordinary or abbarent occurs is using your head. Admitting you have one is not using your head. I have been disposed in the past and whne asked if I have any records at home I honestly say no......I do not have nan "records" at home. Do I keep report sheets? No I do not......do I keep a journal? Yes I do.


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