Would hospital let me review my old charting/documentation?

[northmississippi]

If you needed to see you old charting/documentation to prove you have meds on time, would they let you see it? They say to always document stuff, but what good would that do if it's not available to you when you need to prove something later?

[NightNurseRN13]

If you documented properly then there is no need to prove anything. If something comes up saying you didn't do it, then tell them to look at your documentation. No need for you to review it yourself.

[nurseinsa]

Why would you need to prove you gave meds on time in an old chart? A med error would (should) have been picked up by the next shift or so and delt with already. If there is a coronal inquiry and errors are found you will hear about it in due course, but the coroner would have the documents. If you give meds on time - who do you need to prove it to?

[Esme12, ASN, BSN, RN]

Typically...no.

Once you are no longer that patients nurse you may not go into the record without the patients permission. If you are working one day and you come in the next and want to check, they remain on your unit..... no one will say anything. Once they leave your floor ot the facility..no you may not without permission.

They will allow you to review the record IF there has been litigation filed against the facility or the nurse or if a deposition needs to be taken.

What is going on that you need to review the record?

[northmississippi]

You may not believe this, but their are people that will lie about something you did or didn't do to try to get you in trouble. There must be a better way to cover yourself since documents are gone once the pt is gone.

[Esme12, ASN, BSN, RN]

As a student...your actions are checked by the facility. The hearsay of another student should not affect you. If your faculty have questions they may contact the facility and request a staff review. If it is not your instructors asking you about this leave it alone.

[nurseprnRN, BSN, RN]

Alas, another consideration is that you can chart you gave meds at 0800 even if you gave them at 1230. There may be something else going on, but either way, if anyone ever questions you in a formal setting, s/he will have to have your documentation on which to rely.

[KelRN215, BSN, RN]

You may not believe this, but their are people that will lie about something you did or didn't do to try to get you in trouble. There must be a better way to cover yourself since documents are gone once the pt is gone.

Well, as a student you would not be giving meds on your own so, even if a fellow student lied about you, your instructor should have been there and would therefore know if you gave the meds on time or not. If you were giving meds unsupervised, well then you've got a different kind of problem.

[Rose_Queen, BSN, MSN, RN]

If you were giving meds unsupervised, well then you've got a different kind of problem.

Not necessarily- in my program, once we were signed off by the instructor 2 or 3 times (can't remember which- it was different for first class vs. later classes), we were allowed to give PO and SQ meds on our own unsupervised.

OP, there is no valid reason you would have to review a chart for a patient to whom you are no longer responsible to provide care. That would be a HIPAA violation. If there is an issue which your instructor/school is working through, they will take care of reviewing documentation.