Accessing your own medical record

[CompuNurse]

I have a question, especially for other nurses working with computerized systems. Does your hospital have a policy against staff accessing their own online records? If so, is this policy written or unwritten? Is it based on hospital policy or state law?

The reason I'm asking: I work with testing and training in information systems. The number of test patients in the system is limited due to numerous legitimate factors, and often you need to see how the data is organized in a live patient. Due to confidentiality reasons, I don't chose to access another patient's record for this purpose. Other staff state this is a legitimate reason to access another patient's record, but that they'd get into a lot of trouble for accessing their own record.

I'm unable to find a written policy regarding accessing your own online record.

How is this handled in your organization? Is there some legal recource someone can direct me to regarding this? Thanks.

[rninformatics, DNP, RN]

Hi CompuNurse,

As a rule I have never allowed test patients into the Live database - too much potential for errors. Thats what the test environment is for. I've gotten into the practice (after 7 years in HIS and 10 system installs) of keeping my Test environment up to date for this exact reason. Our test patients are named after Disney/Warner Brothers characters to easily alert our staff should Live somehow become corrupted with a test patient and to differentiate Live from Test. If one goes into an environment and sees Donald Duck or Minnie Mouse in the census they can see that they are in Test and if a requisition inadvertently prints to lab on one of these patients the lab staff knows someone is testing. This also prevents someone from performing a test or procedure on a real human patient should that patient have the misfortune to have the same name as a test patient, i.e. John Smith.

I routinely access live patients to trouble shoot issues in the Live environment/databases. As I am an employee at our facility and this is part of my job there is no breach of confidentiality and i"ve never accessed my employee health record. Employees accessing their own or anyone elses records outside of their job responsiblities is a breach of patient confidentiality, privacy and security per our written and established IS, administrative and HIPAA policies. I'd also suggest you pose your question to the nursing L listserve.

[canoehead, BSN, RN]

I know the policy in our hospital is not to go into your own records. I am cranky enough to say that I have a right to know what's going on with my healthcare whether they like it or not. I go in to look up labs without guilt, but as far as notes someone has written on me I would go through channels for that. I think the person that wrote them should know that I'm looking at them, as a courtesy.

Looking up my own lab results is an issue I would be willing to be fired over. Especially since this is such a small hospital everyone else might know the results before the doc ever was able to call me back.

[CompuNurse]

Thanks for the feedback so far, and I absolutely agree with you that the production data bases should be free of test patients. Unfortunately, I came into this situation with these practices already in place, so it will take some time to correct.

I also agree with you that it is completely inappropriate for a staff member to be using the online EMR to browse or surf for information not pertinent to the work at hand.

I also agree that it is not a breach of confidentiality to log into a patient's chart to troubleshoot a problem with that patient's chart in the system.

My question more specifically, is: In the absence of certain factors (i.e. systems with no test interfaces, etc) that make it impossible to get the information from a test system, and if you need to pull up a live patient chart to get the information you need, is it better to pull up a stranger's chart (which I'm uncomfortable with) or your own chart (which should contain no surprises)?

[Mimi2RN, ASN, RN]

We are not allowed to look at our own medical records, or the record of anyone when we aren't involved in their care. That's to prevent people being too inquisitive, and one nurse was fired for that. There is spy ware in the system, to see where we have been.

[rninformatics, DNP, RN]

Originally posted by CompuNurse

My question more specifically, is: if you need to pull up a live patient chart to get the information you need, is it better to pull up a stranger's chart (which I'm uncomfortable with) or your own chart (which should contain no surprises)?

I had practiced clinically for 10+ years as an RN prior to entering IS/IT so I will compare your scenario above with this. As a student nurse it embarressed me (you wrote you are uncomfortable) to see naked bodies. As an experienced clinician I do not feel uncomfortable doing my job.

The things patients told me and the things that I saw were done so in the context of my job, with respect for my patients and a genuine desire to help. I take the same attitude when viewing patients records in the system and remember to only view what is necessary to get the job done - no more and no less.