Best way to document daily issues as an RN?

[theantichick]

I was advised when I entered the nursing profession to never keep a personal diary about the things that happen on my unit. That I would run afoul of HIPAA issues as well as legal ramifications if I kept an unofficial diary.

Let me say clearly that I have not personally witnessed any issues at this time at my facility that I would be mandated to report.

Should I be witness to issues that compromise patient safety, I would like to know what the best way to handle this in terms of personal documentation would be? I have worked before this in a number of industries and found a personal diary where I documented interactions and behaviors with co-workers and management I suspected would later cause a problem, including names, dates, times, witnesses, saved my behind more than once.

Given that there are a lot more issues to consider as a nurse, and many of these issues can and will result in an official investigation and witness statements, not to mention retaliatory issues from coworkers and/or management... what would those of you with more experience recommend for someone to do in order to cover their own behind?

[RNperdiem, RN]

Your post is a little vague. In nursing, you can fill out an incident report for patient safety issues. For things like falls, IV infiltrates or medication errors, we use the incident report program on our computers.

Also, you can bring things to the attention of your manager if you can clearly state the safety issue/problem and have a recommendation on how the problem can be solved.

[Altra, BSN, RN]

Agree with the above post -- reporting via incident/variance/occurrence report (whatever term your hospital uses) or discussion via email to a supervisor/manager/director provides a paper trail. Same thing with reporting to a hospital's compliance line.

[HouTx, BSN, MSN, EdD]

As nurses, we are 'mandatory reporters'. Our nurse practice acts may differ in the specifics - but the requirement to take corrective action when something is 'wrong' is pretty universal. As professionals, we should also take responsibility to address inter-personal issues with one another rather than utilizing passive-aggressive tactics (e.g., accumulating evidence to use later).

[theantichick]

Yeah, I have to be vague about the details. I'll give an example from a different place.

When I was working in I.T. I once worked with a developer who was inept and when the pressure came on her because of it, she started slinging accusations at some of the rest of us. I started keeping a work diary and included things like when I completed portions of work she was waiting on me for, conversations we had including what was said and who else heard it. This ended up saving my butt several times when my manager followed up on her complaints and in the end after she was fired for inability to do the work but charged that we discriminated against her and created a hostile work environment.

So I'm not talking about keeping a diary of stuff to accumulate and throw all at once nor am I saying I would write things in the diary instead of reporting if it should be a variance. I'm talking about honest to goodness CYA. And I don't think my manager wants a work diary in email every day. But the nature of it in a hospital environment is dicey because patient references may have to be made for context. I think I'm okay with HIPAA if I only use medical records numbers but like I said I was advised never to do it at all.

[jadelpn, LPN, EMT-B]

Unfortunetely, a "diary" is subjective. Especially when recalling specific conversations. And the "witnesses" can hear something differently than you. If someone starts "slinging accusations" this is an issue for the manager to be made aware of, and can be proved/disproved by your documentation.

You can certainly meet with your manager, and perhaps have a union rep as a third impartial person taking notes. Or take your own notes at any meeting.

CYA by documenting appropriately and throughly.

If you are documenting every interaction daily, this is a culture on the floor issue that needs to be addressed. If your locker locks I would keep any notes in there, and not bring it home. If it is a matter of inappropriate communication on a daily basis, have frank discussion with manager on how to change things.

[Guttercat, ASN, RN]

It's no problem to keep a diary of interactions between you and staff and/or management that are work related (not patient related).

I'd be entirely cautious, however, when it comes to documenting any interactions that might include actual patients. That's what charting is for.

Yes, I know, there is sometimes an inextricable link between the two. If you use a diary, utilize common sense.

[Altra, BSN, RN]

I agree that your manager will not want a daily email from you. It's unnecessary. It seems to me that what you're describing can generally be more appropriately covered in patient charting.

Patient's family busting your chops about xxxx? "Patient & family express concern about xxxx. Verbal education rationale for xxxx provided. Family verbalizes understanding."

Problem getting a response regarding xxxx from Dr. A? Document in the patient's chart each time you paged or xxxx was discussed.

Assuming that your workplace is not horrendous -- good charting and an *occasional* email or conversation with a manager or supervisor when something happens that makes you uncomfortable should be sufficient. The kind of *diary* you're describing would indicate to me something highly unusual, out of the ordinary happening.

[theantichick]

Thanks for the feedback. We do have some fairly serious issues in my unit but I can't really go into details on a public forum. There are horizontal violence issues, and some patient care issues.

I had a good chat with my nurse manager and she actually does want me to keep a diary of issues that are compromising teamwork as well as patient care. She's relatively new on the job and the employees haven't realized that she's not carrying on the same management style as her predecessor so they're not going to her with issues and they are festering. She can't fix what she doesn't know about.

So on her instructions I am now keeping a Word document on my network drive under password with documentation of interactions and issues, and only dates and room numbers or medical records numbers if patients have to be referenced. Since it's not leaving the corporate digital drives I shouldn’t have any legal issues.

[Retired APRN, MSN, RN, APRN]

HIPAA was enacted after I left the US, so I don't have any personal experience. However, it occurs to me that you might want to ask an expert to be sure that you are absolutely not violating it by referencing medical record numbers.

In my years of working and just plain living on this earth for 58 years I've learned that I have to choose which hills I'm willing to die on and which I can let go. Before getting involved in something like this, I'd want to be sure I made the right decision. If I am sure, though, I go to the wall.

[theantichick]

Well, if I happened to witness something that requires me to report to the nursing board and involves a patient, they require medical record numbers. Since at this point I'm documenting on the specific request of my nurse manager, and the information never leaves the secure network drives (I'm not taking a copy home on a flash drive) I'm pretty sure I'm legally clear.

I hate being in the situation I'm in, especially as a new nurse, but I believe it's going to resolve relatively soon.