Assisted Living and Documentation

[orionsgirl33]

Hello All,

I have been and LPN for 14 years and have run into a hiccup at a new job. I have never worked in Assisted Living before and here is the question I have:

For charting purposes there is a general (not in the chart) communication book where we write any updates, info to be passed on from nurse to nurse etc. During weekends there is only an am med nurse, then they leave, then later in the pm another nurse comes in to pass meds and leaves. There is always cna's in the building.

My question then comes to the narrative pt notes.... for example, If I had to call and talk to sally lpn about a situation, I would document that I talked to her, explained situation, and whatever the end verbage result is. Or if I talked to the oncall nurse, her name would go in, etc.

Well in finding out, I am not to put nurses names in that narrative note. Only on communication book. their reasoning is that its a hippa violation? and that its not necessary and should only go in the non-record communication book.

My thinking.....If I talk about a situation whether it be nurse or doctor, names go in there. No one is going to know who else I talked too 2 years from now if there is ever a deposition, etc. I am really baffled by this .... am i wrong? are they wrong? thoughts?

Thanks!

[Race Mom, ASN, RN]

I would always document whom you talked to in your narrative notes. I don't understand why your company states that including the nurses name is a HIPAA violation. HIPAA protects the patients information from being disclosed to those that don't need to know the information. Your company needs to hire someone who knows what HIPAA is, plain and simple.