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?
    Joe V likes this.
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  3. 66 Comments so far...

  4. 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.
  5. 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.
  6. 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.
  7. 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."
  8. 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.
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    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.
  10. 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.
  11. 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.
  12. 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.


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