CNA being asked to go through patient med records

[beck_79]

The powers-that- be at work are now trying to implement a new duty for CNAs. We are supposed to go through the patient's charts-their medical records and fill out updated Assignment Cards weekly. We are to go through the patients' records and check off on the assignment card their diagnosis, what kind of transfer they are, do they use assistive devices, dentures, hearing aids, any kind of rehab therapy (splints, heel booties), meal assistance/ diet, continent or incontinent, if they are on blood thinners (to watch for bruising). Then we have the nurse sign it off. The rationale for this is that so people who float will have an up- to- date assignment card from which to work.

I'm pretty sure that this is not my responsibility as a CNA. I'm a nursing student, so I do have some experience with charts, however as CNAs we have not been trained to interpret the information in a chart. If I fill out the wrong info the blame will be on me. Also, shouldn't the patient information we get as aides be on a need- to- know only basis? We shouldn't have access to patients personal information. A few of the aides I work with are not very trustworthy. The charts have private stuff- SS#, addresses, medical history. As a patient, I would not want anyone but the doctors or nurses taking care of me to be able to access my chart.

Where can I go to find out if this is allowed? And if it is not, how can I report it?

[NurseCubanitaRN2b, BSN, RN]

You can look at a patients chart if you're working with that patient specifically. But you can't pick up Joe Blows chart who isn't your patient and read it because you're curious.

[asun21ta]

There are different guidelines depending on where you work and what state you live in. Typically, in an LTC, there isn't a reason CNA's should be in the patient's chart unless it is to view their care plan. At least that is how it was at the last LTC I worked for. We were allowed in the charts to look at their care plans...as it often changed depending on the patients health. I do however, believe we should have access to find out what communicable diseases they may have. I have found that not all nurses remember to advise staff which patients are seriously contagious.

I was pregnant with my daughter when I found out I was caring for a patient with shingles! The nurses in charge didn't tell the the CNA staff about it for days. I just so happened to find out when the dietician mentioned it to me by accident. I refused to care for the resident once I heard that! They are lucky nothing happened to me or my baby! For this reason, I feel CNA's should be granted limited access to chart information. It's just to risky to depend on someone else to tell you what you should know as a caregiver.

As a medical unit clerk, I have found that things I was unable to do as a CNA (such as going through charts and using the Glucometer on patients), I am supposed to do as a Medical Unit Clerk. I am a CNA, but I do not work in an LTC. At an LTC, many times CNA practices are limited to basic care, which is why they don't want you reading charts and interpreting Physician orders. We simply are not trained to do so. If you work in a hospital or some kind of rehab facility, the rules are a bit different. CNA's are not as limited as these places will often train CNA's to read charts and much more.

[KimberlyRN89, BSN, RN]

When I did clinicals at an LTC, we were allowed to look at the patients charts with the CNA's there & our instructor.

I work at an ALF and in each section of the building is a big notebook with all the residents info: DOB,SSN,Place of Birth,Insurance Company & their policy # & what they are diagnosed with. There's also a lot of family information & other things like advanced directives,etc.. Idk it just makes me uncomfortable that they are just laying there in a cabinet where essentially anyone could get to them (they're not locked up). I do agree that I think we should be aware of some things, but other info like DOB,SSN,etc..I dont think that we should have access to that. We have a real problem with dishonesty @ our facility, such as people stealing food from the kitchen, stealing money from others, and taking meds out of the health office. That said, I wouldn't be surprised if someone there tried to steal the residents SSN ::angryfire:angryfire

[asun21ta]

When I did clinicals at an LTC, we were allowed to look at the patients charts with the CNA's there & our instructor.

I work at an ALF and in each section of the building is a big notebook with all the residents info: DOB,SSN,Place of Birth,Insurance Company & their policy # & what they are diagnosed with. There's also a lot of family information & other things like advanced directives,etc.. Idk it just makes me uncomfortable that they are just laying there in a cabinet where essentially anyone could get to them (they're not locked up). I do agree that I think we should be aware of some things, but other info like DOB,SSN,etc..I dont think that we should have access to that. We have a real problem with dishonesty @ our facility, such as people stealing food from the kitchen, stealing money from others, and taking meds out of the health office. That said, I wouldn't be surprised if someone there tried to steal the residents SSN ::angryfire:angryfire

I agree that their personal information should be limited. Anyone could steal their information. However, now that I see the other side of things, I know why some of their personal information (such as DOB, SSN) is available for us to see. You would be amazed at how many people share the same name. This can cause a big misunderstading if you are new and don't know the difference between the two patients. In this case, if you have two patients named John Doe both born in 1927, you could refer to their exact birthday to verify the patient. This numbers have been put in view for employees because serious med errors have been made in the past. Also, the Facility wants to make sure they get paid from the insurance companies. These official legal documents are required to have pertinant information. I think that only the last four of their SSN number should be in view. Everything else, such as insurance carrier & former address is simply no one elses's business but in the business office. At my facility, I have to verify their first & last name as well as their birthday before I provide care.