Looking up patient after discharge

  1. If a patient is discharged and I need some of their Lab values for school paperwork, is it violating HIPAA to open up their records?
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  2. 12 Comments

  3. by   Pepper The Cat
    I believe so. I'm Canadian but when I needed to look at a chart for a paper I was writing when working on my BScN, I had to go through Health Records and get permission.
  4. by   JustBeachyNurse
    Quote from TeenuhVo
    If a patient is discharged and I need some of their Lab values for school paperwork, is it violating HIPAA to open up their records?
    Quite often yes as you are not actively caring for the patient
  5. by   RN403
    We were not allowed to look up patient's charts after D/C. Ask your instructor or the nurse manager and allow them to guide you on how to proceed.
  6. by   jadelpn
    You should not open up a patient's chart after discharge. Further, to use patient information for education purposes--does that require a special consent? In any event, once asking your instructor, you could ask the primary nurse what she remembers about this patient, or if she has a patient brain from that day that you could get some information on. I DO NOT KNOW if this is appropriate in your setting, but opens a good discussion on what to do from here.

    If you know that you need to have a general overview of a patient for your schooling, make sure you make GENERAL notes--nothing that will identify specific patients. Speak to your instructor about this, as I am sure you are not the only one who finds they need information after the fact.

    Old school, yes, but index cards that fit in your pocket are good things. Identified only by diagnosis, age and sex of the patient. On it, just labs that not within normal limits, other information you may need. As you think of it (and soon you will feel like you are doing this stuff in your sleep HAHA) a couple of nursing diagnosis as well. Those cards will make up a brain for you of epic proportion!!

    (and just as an aside, you should have a card that has all general labs and their normal limits on them.--I taped that to the bottom of my school clipboard for reference)

    Best wishes!!
  7. by   LoveMyBugs
    Yes it is a HIPAA violation.
    A nurse from my facility was just fired for doing this.
    You need to get the floor managers approval, or because you are a student, discuss with your instructor on how best to proceed.
  8. by   Jory
    An exception to HIPAA is the education of healthcare workers. You only need to obtain permission through the appropriate channels, then it's not a HIPAA violation anymore.

    But accessing it without permission of the facility is a HIPAA violation will absolutely get you fired.

    It's that simple folks. We have 5 nursing schools in this area.
  9. by   MatrixRn
    Quote from Jory
    An exception to HIPAA is the education of healthcare workers. You only need to obtain permission through the appropriate channels, then it's not a HIPAA violation anymore.

    But accessing it without permission of the facility is a HIPAA violation will absolutely get you fired.

    It's that simple folks. We have 5 nursing schools in this area.
    Totally agree. For education purposes we are granted a little leeway, but the chain of command must be followed.
  10. by   BuckyBadgerRN
    During clinicals, a patient only stayed "active" in the computer system for a short period of time, after that you needed special access in order to view anything in the chart. We as students of course didn't have that =) If we needed things like lab values or other results, we were allowed to go down to medical records and they would print off what we needed, blacken out vital statistics and let us take ONLY the bare minimum of what we needed.
  11. by   MommyRN89
    If a patient is transferred to a different floor but you forgot to chart something so you do it later after they're off your floor, is opening their chart at that point a Hipaa violation?
  12. by   JustBeachyNurse
    Quote from MommyRN89
    If a patient is transferred to a different floor but you forgot to chart something so you do it later after they're off your floor, is opening their chart at that point a Hipaa violation?
    No because you have a legitimate reason to add to the record. Sitting and reading the chart could be though
  13. by   Tenebrae
    As a student when ever we did an assignment on a patient, we went through a consent form that gave us permission to access their information for the purposes of the assignment only. A copy of the signed consent was also given to the patient (if they wished) and on their patient record
  14. by   Accolay
    Pretty sure that as a student looking up a discharged patient is the fastest way to get kicked out of nursing school, if only to set an example. Your mileage may vary.

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