Keeping A Written Record Of The Patients You've Had: Good Or Bad? - page 7

by All4NursingRN

19,470 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. 1
    Quote from GrnTea
    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.
    I'm inclined to agree with this.
    GrnTea likes this.
  2. 1
    You 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.
    GrnTea likes this.
  3. 2
    What 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.
    salvadordolly and GrnTea like this.
  4. 1
    Here 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.
    Esme12 likes this.
  5. 0
    This 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.
  6. 0
    Keep your notes locked on the unit. Never, never, never remove them from the hospital unless they are totally, and I mean totally scrubbed of all possible identifying data. There's a sticky thread at the bottom of the HIPAA Forum that will tell you what those are.
  7. 0
    Quote from calivianya
    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 have to say, this is not a good situation in which to be. I have heard stories (and, yes, they are just stories, so some facts may be embellished), however, they involve someone who is no supposed to have access to this information making this information public (a child, an angry ex, an otherwise well meaning spouse) and the person who was keeping the information "safe" now gets in big trouble.

    Ask your preceptor if they can keep it in their locker for you, but do not (ever, never) take it home with you.


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