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CNA's and Looking at Charts

HIPAA   (6,638 Views | 10 Replies)

cd365c specializes in none.

1 Article; 7,572 Profile Views; 109 Posts

As a CNA where I work, are we not allowed to look at patient's nursing charts that are ours? I wondered because I am wondering what the person is admitted for, what the nurses are finding in assessment, and meds that they are on. Of course I think this is different than looking on someone who isn't your patient (which is a definite no).

As a nursing student, I have many interests in learning about patients. Again, I would be doing this in downtime and not during busy points.

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1 Follower; 2,617 Posts; 38,324 Profile Views

You should speak with your supervisor about this.

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

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Information that is not needed to do your job is not your business. If you are not making clinical decisions (CNAs do not) or administering medications the nursing assessments and medication profile are likely unnecessary information for you to complete your job. When I worked as an aide, we obtained vitals but were required to report to the nurse. The nurse entered the vitals and acted upon them per plan of care. Therefore we did not get access to the medical record. We had printout of orders (ECG, labs to be drawn, X-rays to transport patient for) that had the minimum information needed to complete our job quickly, safely & accurately.

Check with your supervisor. Curiosity as a nursing student can cause issues when working as an NA/CNA

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JustBeachyNurse has 10 years experience as a RN and specializes in Complex pediatrics turned LTC/subacute geriatrics.

1 Follower; 1 Article; 13,946 Posts; 100,851 Profile Views

As a nursing student, I have many interests in learning about patients. Again, I would be doing this in downtime and not during busy points.

This will get you in trouble. This is not your privilege to know and not necessary for you to do your job. If your employer gave you access to read about "your" patients on down time that would be a HIPAA violation.

There are a multitude of case studies available from a variety of sources for you to learn from, plus clinicals as a nursing student

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Cohiba specializes in Nasty sammiches and Dilaudid.

161 Posts; 4,160 Profile Views

As the others have said, check with your supervisor but IMO you'll need to be able to articulate a far better and more specific reason than "I'm curious" for accessing a chart, i.e. checking to see if the patient is on vasoactive meds and/or orthostaticlally stable before you get them up to ambulate/toilet and have their BP plummet.

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4 Followers; 37,684 Posts; 103,154 Profile Views

There is nothing about your job that the nurse can not, or should not, be able to convey to you without you accessing the chart. At a facility where I once worked, it was a CNA who started the gossip mill about something very sensitive concerning one of the residents. That CNA gleaned the information from looking at the chart. As part of the investigation, the CNA was fired and the supervising nurse was reprimanded. If anything were to cause problems along those lines, you couldn't prove you weren't the source if it is common knowledge that you've been in even one chart. Stick to your job.

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RedInScrubs has 3 years experience as a ASN, RN and specializes in Medical-Surgial, Cardiac, Pediatrics.

136 Posts; 3,196 Profile Views

As a CNA, you need to remember that when you're working, you are working under your scope as an assistant, and you are limited to that, even if you have some higher training as a student nurse. If policy at your facility says you don't, and looking at charts is not needed to provide the care within your designated scope according to your license, than you shouldn't do it while working, because you can get into hot water with HIPAA for doing so.

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556 Posts; 8,828 Profile Views

I worked in a SNF where the CNA's basically ran the place. I had CNA's read pts charts and call the families and report changes in meds or lab values. The DON/ADON did nothing about it. CNA's would break HIPPA all the time. I quit after 7 months of that hell.

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1 Follower; 51 Articles; 4,800 Posts; 93,910 Profile Views

Learn to ask the questions--"How independent is this patient?" "Is the patient bedbound, or do they have an activity order?" "Special diet?" "Can the patient ambulate, and if so, do they need an assistive device?" And your most important "Is this patient a one or 2 person assist, or do you use a lifting device?"

CNA's do need to know some information relative to the job at hand. So they are not in a situation where the patient is not safe. CNA's are also the eyes and ears--they are usually the first ones who notice something is amiss "The patient in room 788 is a 2 person assist, and yesterday I was able to get the person up independently. Could you please come and assess?" Or even "there seems to be some breakdown on the patient in 572's coccyx. Could you please come and assess?".

What you do not want to do OP is to start looking through charts. Yes, it can be a good learning experience, however, be mindful of that when you are a student nurse in clinicals. THEN would be the time to look at your chart, look at your orders, look at your meds, significant labs....as it pertains to the care you will give as a student.

Otherwise, for your job, you most certainly should ask questions, report what is not a norm for the patient, or any other red flag that you find with whom you are assisting.

Best wishes!

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cd365c specializes in none.

1 Article; 109 Posts; 7,572 Profile Views

I really do appreciate all the responses. I don't want to be fired for breaking HIPPA. Instead of talking to my manager, it seems that I can clearly articulate the huge risks of doing this. The reason I questioned it is because of the gray area I feel it falls into.

Again, I feel dumbfounded that I thought I could do this legally now.

Have you ever heard the term "CYAs". My nursing instructor used it all the time. "Cover your assests".

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452 Posts; 9,031 Profile Views

I really do appreciate all the responses. I don't want to be fired for breaking HIPPA. Instead of talking to my manager, it seems that I can clearly articulate the huge risks of doing this. The reason I questioned it is because of the gray area I feel it falls into.

Again, I feel dumbfounded that I thought I could do this legally now.

Have you ever heard the term "CYAs". My nursing instructor used it all the time. "Cover your assests".

I like your response...and it's HIPAA, not HIPPA. :) Also, I use the term CYA daily @ work.

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