Access to medical records

Nurses General Nursing

Published

A nurse is probably trying to *** me because the hospital screwed up pretty badly and so now he claims he cannot let me review the last note the physician/resident wrote during rounds or review lab work with me. It literally takes 10 minutes. He said they make even patients use mychart. 

I am listed on the paperwork they provided for POA as an alternate. The way the document is worded is that alternates have access to medical documents and patient records immediately if he cannot make decisions. This is from the state and the hospital had us fill it out.
 

I do know that we are pissed about multiple botched procedures. Like I am pretty forgiving but I honestly feel like they almost killed him. I have a tad bit feeling that day shift RN may have made notes and hid them from the patient mychart as facility allows nurses to hide notes. 
 

I do feel better about the prognosis as it probably is fixed and I am impressed with the attending note analyzing some potential fever causes. 

Anyway, is this a policy at your hospitals? That patients and their POAs cannot access medical records or review it with the nurse? they are claiming that patients cannot review the notes or lab work either. No policy provided.


I'm threatening tomorrow to make the resident come down in the morning and read off every lab value to me as the nurse said he could see if the resident would review it with me.

Specializes in Critical Care.
ApplePineApple said:

I am concerned about some of the responses here though. It doesn't seem like you guys would be providing adequate care.

Agreed with Wuzzie. That's a super condescending line to drop if you're basing the entirety of care on your clearly incomplete knowledge of law and facility policy.

You're mad because you're not getting the answer you want but really this isn't the place. Your complaint will be best addressed locally depending on your state, facility, and patient circumstances. 

And the responses made by the OP here are why I'm glad I no longer have to deal with families.  PACU is a glorious place to work.

Specializes in ICU.

From what I am familiar w at this point is that:

1. Families at both hospitals I work at are welcome to provide emails which give them direct access to MyChart. The results on MyChart are pretty quick to result and many patients find this useful.
2. As a nurse, it is our practice to never truly tell patients and their HCPs exact lab values. This is not truly within our scope and it should be the physicians explaining the results and about the results to patients and families.

* With that being said, if I'm being pressed about patient results I either call the physician who will go over it w them or get management involved if it's escalating. Our license is always at stake and you want to be safe - families and patients need to be respectful for that

Hope this helps!

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.

It certainly is within an RN's scope to share and explain lab values. 

Specializes in Critical Care.
ApplePineApple said:

A nurse is probably trying to *** me because the hospital screwed up pretty badly and so now he claims he cannot let me review the last note the physician/resident wrote during rounds or review lab work with me. It literally takes 10 minutes. He said they make even patients use mychart. 

I am listed on the paperwork they provided for POA as an alternate. The way the document is worded is that alternates have access to medical documents and patient records immediately if he cannot make decisions. This is from the state and the hospital had us fill it out.
 

I do know that we are pissed about multiple botched procedures. Like I am pretty forgiving but I honestly feel like they almost killed him. I have a tad bit feeling that day shift RN may have made notes and hid them from the patient mychart as facility allows nurses to hide notes. 
 

I do feel better about the prognosis as it probably is fixed and I am impressed with the attending note analyzing some potential fever causes. 

Anyway, is this a policy at your hospitals? That patients and their POAs cannot access medical records or review it with the nurse? they are claiming that patients cannot review the notes or lab work either. No policy provided.


I'm threatening tomorrow to make the resident come down in the morning and read off every lab value to me as the nurse said he could see if the resident would review it with me.

Even as a nurse myself, I am not allowed to SEE my own chart while being treated. It's a HIPPA thing. It's reality. And I wouldn't show you anyone else's chart either during their stay in the hospital. No way. 

Who cares about some "policy" - it is inappropriate and against the law.

Also, as a nurse, I am not to review lab results with patients/ POAs, etc because I collect the data but I DO NOT interpret it: that is the doctor's role. I'd be going outside my scope of practice and breaking laws if I did the things that you are complaining about. 

Also, 9 times outta 10, questions like these, threats like these, are both unhelpful and take away from the actual patient care. You come at them with wrath and you're going to be met with apathy because honestly its a waste of time - we have people to take care of. 

Could you imagine if people had real time access to every single lab drawn? Sometimes when we draw a lab, or when I'm training a new nurse to draw labs, and the patient has poor access, and the blood needs to be taken from an IV vs a direct stick, but then the new nurse didn't waste enough fluid ( so then the blood is mixed with saline fluid, which means its a diluted, inaccurate sample) and then that sample resulted: could you imagine the amount of freak out and chaos that would occur if people could see that in real time? 

What do we do when a diluted or questionable sample happens? We take another one to ensure accuracy. If there are questions about how a procedure was done / should be done, we explore that and improve and correct any processes that were not done right. Also Im not sure what kind of procedures you're talking about - as nurses we don't do what people consider "procedures" so I'm not sure why your anger is at nurses. 

To be straight forward: we do not have the time and resources to address every freaking complaint and phone call that comes are way that most of the time doesn't even apply nor helps your loved one in any way.

The more time a person takes away from the direct patient care, the more likely that its the patient that will suffer, because time is allocated to your complaints vs the care that the patient deserves. 

If you want to contribute to the already existing high burn out in health care - which would lead to even shorter staffing, poorer quality of care, more mistakes, fewer answers - then complain away. 

Specializes in Critical Care.
LovingLife123 said:

And the responses made by the OP here are why I'm glad I no longer have to deal with families.  PACU is a glorious place to work.

So tempted to leave ICU again and go back to PACU or another procedural area simply because of this. 

Specializes in OB-Gyn/Primary Care/Ambulatory Leadership.
BeatsPerMinute said:

Even as a nurse myself, I am not allowed to SEE my own chart while being treated. It's a HIPPA thing. It's reality. And I wouldn't show you anyone else's chart either during their stay in the hospital. No way. 

Who cares about some "policy" - it is inappropriate and against the law.

Also, as a nurse, I am not to review lab results with patients/ POAs, etc because I collect the data but I DO NOT interpret it: that is the doctor's role. I'd be going outside my scope of practice and breaking laws if I did the things that you are complaining about. 

So much incorrect information in what is quoted above. First, HIPAA (1 P, 2 A's) laws do not apply to a person viewing their OWN medical records. It just doesn't. Do not conflate a facility's individual privacy policies (which differ from organization to organization) with HIPAA laws (which do not differ). 

And yes, it is absolutely within your scope to discuss, review, and interpret lab values. You just cannot make a diagnosis based on those values (e.g. you could say "your WBCs are critically low, this means that your body can't fight off infection as well, so you could become sick with other infections, or it might mean that your body has used them up fighting an infection" but you cannot say "your WBCs are critically low, this means you could have leukemia"). An RN, by very nature of her licensure, has the training to know what specific labs measure, and whether or not a person's lab value is WNL or not. They absolutely can share that knowledge with patients.

Specializes in School Nursing.
LovingLife123 said:

You have to go through appropriate channels to get medical records.  This was little hard for me to understand, but if you want medical records and are the POA you can go to the medical records office and request the records or you can go into my chart and see some things.  
 

But I don't share notes and allow people to view charts when I have them pulled up.  

I went through something like this with my Mom. I am her Health Care Proxy, my brother is next and is her POA, and my cousin is third. My cousin requested medical records and was denied. She asked my brother to get the records for her and he was denied as he is not her Health Care Proxy. The POA is only to sign documents and take care of her finances. Any medical decisions are made by me, and only the health care proxy can obtain those records. I do always consult my brother with any decisions that need to be made. I feel that just because he's not the proxy, he is still her son and should be included in the decisions made. 

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