disappearing nurses notes!

Nurses General Nursing

Published

Is it legal for the DON to make pages of nurses notes ( paper charting) disappear ? I documented 2 pages of notes on tuesday on a resident about the resident complaining of pain and not recieving prompt calls back from the md and pharmacy. It took 4 hours to get the pain medicine. And when I came in to work today all my charting was gone. The other nurse I work with said the DON has the tendency to make certain charting "disappear " if she does nt like its contents. Is this legal ?

If you make copies where should you keep them? I was told that if you keep them in your locker off of the unit that isn't permitted, but say you keep them on the unit in a note book that gets hidden or lost??

I wouldn't keep anything hidden on the unit. Somebody will be sure to find it and it won't happen at a good time and they will figure out it was you because it concerns you.

If you make copies where should you keep them? I was told that if you keep them in your locker off of the unit that isn't permitted, but say you keep them on the unit in a note book that gets hidden or lost??

Keep them in your house, where else would you put them? Just don't tell anyone that you have them. It is your secret, if you should need them in the future. You know that the hospital would throw you under the bus, if they ever got sued. And just FYI- NSO is only $98.

JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Somewhere in the PACNW

Specializes in OB, L&D, NICU, Med-Surg, Ortho.
I would even go to the CEO/President because it may be a possibilty they know and in on the illegal scam. I would make copies of every note you write with patient names, date, and time and put them in a safe place. You would have your proof. I would call state board of nursing and/or Joint Commission. The physicians should be reading these notes and should have questions about things being missed. They maybe in on also. It appears to me this place is a set up for failure no matter which way you move or go. Good luck.

The problem is this: it can be considered a HIPAA violation (I was told). I had a pt hemorrhage and made copies of my detailed notes because the doctor wanted to review the case the following week. I was told by my director that I was violating HIPAA by keeping a copy of those notes in my locker. I did not take them OFF the facility grounds.

So...darned if you do...darned if you don't..

Specializes in acute care med/surg, LTC, orthopedics.

We have to act defensively because our workplaces have made us suspicious and paranoid, they would incriminate us in a heartbeat if it meant saving themselves, that's how it works. Which is why I wouldn't hesitate (and have in the past) to make copies of anything I felt was pertinent and as long as you're not sharing the info with anyone you're not breaching any confidentiality laws.

Specializes in Trauma, Teaching.

Notify the BON. Your nursing license is being put at risk, you need to make the appropriate reports.

Call the state ombudsman, ask for a review of your patient's care.

Does your facility have a legal rep? Notify them that charts are being altered.

Get your resume up to date.

The problem is this: it can be considered a HIPAA violation (I was told). I had a pt hemorrhage and made copies of my detailed notes because the doctor wanted to review the case the following week. I was told by my director that I was violating HIPAA by keeping a copy of those notes in my locker. I did not take them OFF the facility grounds.

So...darned if you do...darned if you don't..

Actually,making copies of your notes is more then just a HIPAA violation. It is a violation of several laws. No one, not even a physician can make a copy of a patient's medical record without written consent of the patient or a legal representative. One cannot even remove a patient's record for any type of inhouse review. I worked as an Assistant Administrator in a teaching hospital. Charts up for utilization review had to be reviewed in the nurse's station. Patients selected for Grand Rounds, the staff-residents, attendings and nurses taking part, had to rely on their own handwritten notes, that is how strict the laws were in my state. Medical records, regardless of the type of institution, are strictly protected,by law.

GrannyRN65

Specializes in Health Information Management.

You're in a tough spot, but I must firmly disagree with the "just make copies and hide them in your house" advice. That could get you into major, MAJOR trouble - it's a violation of HIPAA that could result in heavy fines or even jail time. Those records aren't yours to copy or conceal in your home!

If you have an ethics or compliance hotline at your facility, now's the time to use it. If not, try (anonymously) contacting the head of your documentation/health information management department - they tend to take strong exception to parts of the legal health record magically disappearing. You could also try anonymous messages to your company ombudsman or even the CIO or CEO. Perhaps you could try the BON if you can't get anyone in the facility to intervene. But please don't do something illegal in an attempt to protect yourself from the consequences of someone else's infraction!

Specializes in Tele, ICU, ED, Nurse Instructor,.

Do you have a locker at work. If you didnt document you didnt do it. So you are telling me if you assessed your patient and written a note and the note is gone. You didnt do your work because you didnt document. So d*mn if you do and d*mn if you dont. If you are not protected by your NM and you are not able to protect yourself. You tell me who going to protect the nurse. I know plenty of nurse keep things from pass patient up to 6 months just in case something comes back and bite him/her in the butt. CYA!!!!!!

Specializes in Tele, ICU, ED, Nurse Instructor,.

You made copies for the doctor not for yourself to review the following week. The doctor can make their own copies. The doctors can also review charts by requesting them from medical records. As nurses we are not able to request charts for are usage. I am glad I dont work in a place like this because I would be on pins and needles everyday I work.

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