Recently a patient and family member questioned me what their physician was saying about the case, we reviewed the notes together with the permission of the patient.
Both the patient and the family member who intentionally stayed at the patient's side to act as an advocate denied that the physician had been in to the patient's room that day even though there was a complete head to toe assessment with problem list and plan.
The patient now stated that since I am aware that there is documentation that they say is fraudulent I am being held accountable by them to report the incident, which after confer with the house supervisor on a weekend I reported to the unit manager.
I have been questioned multiple times regarding this incident and the issue continues to be the discussion with the family not the fraudulent documentation of the MD. I feel like my job is in jeopardy now even after a conversation with my manager.
Will human resources or any other pathway be helpful in preserving my position. I will be completing my BSN in December and will have more flexibility after completion of my degree to change facilities.
My facility requires any person wanting their medical records to request it through the medical records office. Patients do have access to an online portal/account that they can access their EMAR, labs, healthcare team members names, and a few other things from. No physicians or nurses notes though.
What do you do if the patient wants you to read the physicians note? Do you read it word for word or paraphrase it? Just curious what other people do.
I can see how it would be frustrating for a patient who might not have remembered the doctor visiting (or remembered what the doctor said), and for that patient to know the nurse has access to the physicians notes but the nurse can't share them. I blame the physicians for not explaining things clearly to patients in the first place. My favorite is when the physician doesn't call a confused patients family member and update them.. even though I have asked them to.
Specializes in Mental Health, Gerontology, Palliative.
Although I agree with the last two posts about the legalities of this situation, I want to voice a personal opinion about this. Being that I'm in the Healthcare field, I know that if i am the patient there are continuous progress notes documented in my chart, and it is MY chart after all, why shouldn't I be allowed to see it? If there's a full head to toe assessment in there from a doctor I never met, but will be billed for seeing, I'd raise hell too.
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No ones denying you access to your file. What they are saying is that every facility has a process around allowing patients to see their notes that has to be adhered to.
I blame the physicians for not explaining things clearly to patients in the first place. My favorite is when the physician doesn't call a confused patients family member and update them.. even though I have asked them to.
This might not always be an accurate assessment. I can tell you for a fact there have been a few times when I spent an inordinate amount of time with a patient only to have them ask me later in the day when I was going to "see" them.
As for calling the families that is a huge time killer, necessary of course, but remember there are times when I have called and couldn't reach the family or was putting off calling because there was no urgent news and I knew the family was going to keep me on the phone longer than I could afford to spend until I had my more pressing patient care issues taken care of.
I try to always give other members of the team the benefit of the doubt when patient's or families verbalize concerns about their treatment and would hope my nurses, techs etc. give me the same courtesy before deciding to "blame" me.
I can't see how it's possible to both limit a patient's access to their own information, and at the same time ensure that patients are fully aware of their conditions, labwork, etc so that they can make fully informed decisions. Those two things seem contradictory.
How does the raw data in people's charts "inform" them to make decisions? How helpful and enlightening do you expect a list of lab values or a radiology report to be to a member of the general public, or even most healthcare providers if the problem is something outside their specific specialty area? It's the education, interpretation, and guidance from providers that helps people make "fully informed decisions," not the raw data.
You could just as easily say let's do away with requiring prescriptions for many medications -- just let people do their own research and decide for themselves whether a particular drug is a good choice for them. (If you think that's a good idea, also, I can respect that -- but I consider it a recipe for disaster.)
What do you do if the patient wants you to read the physicians note? Do you read it word for word or paraphrase it? Just curious what other people do.
I've never worked anywhere with a policy that would allow that, but, if I did, I would just decline to do it and refer the person to the physician for any questions that s/he has about the physician's documentation. There is no way I would be willing to open that can of worms.
I have had plenty of situations over the years in which people have asked about documentation and, while I did not pull out the chart and suggest we sit down together and have a good read, I've been happy to discuss with them generally what I have documented about them. But I am only responsible for my own documentation, and I'm not going to sneak around behind any colleagues' backs and disclose information that they don't know is being disclosed. I would expect the same courtesy from them.
This might not always be an accurate assessment. I can tell you for a fact there have been a few times when I spent an inordinate amount of time with a patient only to have them ask me later in the day when I was going to "see" them.
As for calling the families that is a huge time killer, necessary of course, but remember there are times when I have called and couldn't reach the family or was putting off calling because there was no urgent news and I knew the family was going to keep me on the phone longer than I could afford to spend until I had my more pressing patient care issues taken care of.
I try to always give other members of the team the benefit of the doubt when patient's or families verbalize concerns about their treatment and would hope my nurses, techs etc. give me the same courtesy before deciding to "blame" me.
This is all true, and thanks for pointing it out. I was referring directly to specific physicians at my facility who refuse to call family. We have at least three who will not call and update family members, even if that family member is the patients decision maker.
I wouldn't be frustrated if it were the family just wondering how their loved one (the patient) was doing in general. I can mostly answer that. But when they have specific questions pertaining to discharge, medications, tests, I can't always answer those questions. I know it's a time killer and that physicians are already stretched to see too many patients than they have time for each day, but for important information that nursing staff can't answer, I really expect the physician to call. Unfortunately, these select physicians never do, and I am stuck dealing with a frustrated and angry family member the best that I can.
This might not always be an accurate assessment. I can tell you for a fact there have been a few times when I spent an inordinate amount of time with a patient only to have them ask me later in the day when I was going to "see" them.
As for calling the families that is a huge time killer, necessary of course, but remember there are times when I have called and couldn't reach the family or was putting off calling because there was no urgent news and I knew the family was going to keep me on the phone longer than I could afford to spend until I had my more pressing patient care issues taken care of.
I try to always give other members of the team the benefit of the doubt when patient's or families verbalize concerns about their treatment and would hope my nurses, techs etc. give me the same courtesy before deciding to "blame" me.
I agree with you and try to explain things to the families in a diplomatic way that physicians may be involved in something else. However, I do also feel like if the family ultimately complains, I as the nurse am much more likely to take the fall for their dissatisfaction than the MD.
How does the raw data in people's charts "inform" them to make decisions? How helpful and enlightening do you expect a list of lab values or a radiology report to be to a member of the general public, or even most healthcare providers if the problem is something outside their specific specialty area? It's the education, interpretation, and guidance from providers that helps people make "fully informed decisions," not the raw data.
You could just as easily say let's do away with requiring prescriptions for many medications -- just let people do their own research and decide for themselves whether a particular drug is a good choice for them. (If you think that's a good idea, also, I can respect that -- but I consider it a recipe for disaster.)
I don't think I ever suggesting just giving patients "rad data" without the accompanying interpretation that a nurse is expected to provide, patients will have questions about their findings, that's why nurses exist.
I'm not suggesting a physician should be removed from the prescribing process any more than I'm suggesting we should remove the nurse from the patient advocacy and education process, I'm actually suggesting the opposite; the the nurse should be involved in patient advocacy and education, which includes ensuring they are kept updated and have adequate knowledge of their plan of care and status of that plan.
How is it better for a patient to not know they need to have a potential malignancy that the doctor neglected to tell them about followed up on?
So I bring the WOW in. Pull up the doctor's note. It mentions the possibility of malignancy. The pt asks, "what type of malignancy is it? What is the treatment? What are my odds? Etc." I now have a panicked patient who has a ton of questions, and I have no answers. If they want to review a doctor's findings/notes, the doctor will be notified and they will go over it in the morning when the doctor come in.
So I bring the WOW in. Pull up the doctor's note. It mentions the possibility of malignancy. The pt asks, "what type of malignancy is it? What is the treatment? What are my odds? Etc." I now have a panicked patient who has a ton of questions, and I have no answers. If they want to review a doctor's findings/notes, the doctor will be notified and they will go over it in the morning when the doctor come in.
So I bring the WOW in. Pull up the doctor's note. It mentions the possibility of malignancy. The pt asks, "what type of malignancy is it? What is the treatment? What are my odds? Etc." I now have a panicked patient who has a ton of questions, and I have no answers. If they want to review a doctor's findings/notes, the doctor will be notified and they will go over it in the morning when the doctor come in.
It's better that they never know about it?
How did you get "never" out of the quote above? psu clearly states that s/he would refer this to the appropriate physician to discuss with the client, not that the client will "never know about it." Where are you getting the idea that the only two options for clients are a) being allowed to read their chart whenever they want to or b) living in ignorance?
Karou
700 Posts
My facility requires any person wanting their medical records to request it through the medical records office. Patients do have access to an online portal/account that they can access their EMAR, labs, healthcare team members names, and a few other things from. No physicians or nurses notes though.
What do you do if the patient wants you to read the physicians note? Do you read it word for word or paraphrase it? Just curious what other people do.
I can see how it would be frustrating for a patient who might not have remembered the doctor visiting (or remembered what the doctor said), and for that patient to know the nurse has access to the physicians notes but the nurse can't share them. I blame the physicians for not explaining things clearly to patients in the first place. My favorite is when the physician doesn't call a confused patients family member and update them.. even though I have asked them to.