Chart Following and legal limitations

[Gladhill]

I'm a relatively new acute care NP on a busy trauma/EGS service. We routinely flip-flop between three different ICU teams within our service. We frequently have complex patients with multiple injuries and comorbidities. I may be on one ICU team for three to five days in a row, and then be off for a couple days, and then either return to that same team or switch to another, and then the whole process repeats.

I know that when I was a bedside nurse and my direct care of a patient was over, even if I was back the next day, I could not access that patient's chart. However, I'm unclear if those rules have changed at all now that I'm a provider. If I take care of that patient for multiple days, it's helpful for me to know if my care adequately treated them, if I missed anything, what could have been done differently, etc. However, I'm not clear if I'm allowed back in their chart for review during my days off or on days when I'm on one of the other two teams in my service. (To be clear, in the situations I'm describing, the patients are still on my team's service. I just don't personally have that patient that day.)

I hope that makes sense. I'm just trying to become a better provider, and that's sometimes tougher to do if you're not sure exactly what happened to your patient after you took care of them.

 

[Tegridy]

You are fine if they are on your service. Looking back on someone to make sure you didn’t miss something while a pt is in a current hospitalization on your service even if seen by a diff person that day isn’t going to violate HIPAA. 
 

chart hopping is much stricter it seems for nursing staff than provider staff though both should use judgement when looking in charts and obv not look in random charts. but a patien under your groups service is almost never going to violate HIPAA as you should probably know a bit about all of them anyway since it’s a single group

charts labeled confidential (which is odd since they are really all confidential) may be another story but even then what if you get paged about a pt (im not sure how you all hash out who gets paged over what) you can obv go into it then as. It’s direct patient care. 
 

 

[Corey Narry, MSN, RN, NP]

I work in an in-patient service where we also have different NP's caring for our patients each day they are admitted because we're not always there 24/7. Once you have been a provider for a patient on your in-patient service, you are already part of that patient's care team. That means you can access the medical record even though another provider on your team is caring for that patient on a given day. If you're still hesitant about accessing the record, you could also just ask the other providers how things are going with the patient.

[Glycerine82, LPN]

If the answer to this is no we’re in serious trouble.