DNR bracelet with DNR written on it. HIPAA???

[FireStarterRN]

I was at a committee meeting today. We discussed color coded bracelets that our hospital is considering. One of them is a blue bracelet for DNR patients. It was mentioned that they also want to write 'DNR' on it.

I feel strongly that this is a violation of patient privacy. It advertises to any visitor that the patient has made the decision to be a DNR. I was very vocal about my feelings regarding this. I was the only bedside nurse in the meeting. I think this is basically 'outing' the patient to the world. Many members of the public know what DNR means. It can cause dissension between family members, it can cause people with more extreme views regarding extension of life to make trouble for decision making family members, and it's making visable to any visitor the private information of the patient.

I feel strongly that a blue bracelet should suffice to communicate with members of the healthcare team and that adding DNR to the bracelet is wrong.

Any imput on this would be appreciated.

[ncmc3132]

adding DNR to the bracelet would be a HIPPA violation---a color coded bracelet is all you need

[blueheaven]

Well, at our facility the patient's chart goes with the patient for any testing - code status (if DNR or versions of such) are in front of chart when opened. ALso, computer would have status...and most likely if your patient was off floor for ultra sound - and a code blue is called - the RN or charge from our floor would respond to that area.

It's not a perfect system-but it's a huge deal on our floor to know the code status of our patients since we see so many....unfortunately.

It is a huge deal, I transferred a patient to regular floor one time, and 2 hours later they called a code for her room, I ran down the stairs before they could really get going...she was a DNR, they thanked me because "she just got here" and they didn't really know. I know I told the primary nurse

I work in an ICU so if the patient is off unit, one of the nurses is with him/her. A bracelet would help if it was a pt coming from a regular unit. Usually if we are sending someone out of our facility, we send a copy of the chart (not the whole chart) because we use exclusively computerized charting, and if they were DNR they would also have a bracelet on (state regs)

[kukukajoo, LPN]

Speaking of DNR, Here in NH we have a portable wallet sized DNR card! It is hot pink and is signed by the doc and if you ask me the best thing to come along in a very long time!

[kukukajoo, LPN]

I found this link with great information on the portable DNR card and it recommends jewlery as an option. It has some good information!

http://www.nhchurches.org/index.php?option=com_docman&task=doc_download&gid=21

[GregRN]

adding DNR to the bracelet would be a HIPPA violation---a color coded bracelet is all you need

Are you sure?? Source? A blue bracelet, code for DNR, is protected information under HIPAA (not HIPPA...pet peeve) but putting DNR on that same bracelet is protected information? You might want to research that one...

[Kunzieo]

this is a hipaa violation ..everything you have mentioned here is in violation of confidentiality. anyone can walk in these rooms and get information if they are just left hanging around. not to long ago anything that had the patients name on it had to come down at my job including the names outside the door, names on the outside of the charts and anything else that could identify a patient.

no no no! it isn't! confidentiality and hipaa are two seperate issues. most of the hipaa act pertains to electronic transmission and storage of protected health information. it deals with how hospitals, md offices, pharmacies et al have to store the information with secure networks and computors, and how it is transmitted, via email, fax, etc.

where the confusion comes in is that a bunch of corporate healthcare lawyers decided to take this way too far...and make all kinds of silly rules for the healthcare institutions that they work for...in case a patient ever decides to sue because his/her privacy was violated. that's were rules like "you can't give information about a patient over the phone" and "you can't have a patient's name on a door or a board at the station" and "you must stand behind this sign" at pharmacies and healthcare facilities came from.

it is all a result of this sue-happy society we live in.

while personal privacy must be protected in patients (during bathing, toileting, etc.), the effort to wipe out any evidence that a patient is even in the hospital is ridiculous. why don't we just use numbers instead of names? then we won't ever have to worry about anyone's privacy being "violated.

[Murse901, MSN, RN]

This is NOT a HIPAA violation...(think of I/O sheets, lab-draw sheets, charge sheets, etc that hang in the room...legally, it's akin to that.)

However, ethically...it's stupid to write DNR on the bracelet. I agree with the OP, the colored band is appropriate and sufficient.

This may have already been address by someone else (I haven't read all the replies yet), but DNR is considered Protected Health Information because it relates to a healthcare decision that the patient has made and relates to the overall health status of the patient.

The other things that you mentioned are not necessarily considered PHI (not to mention they are not usually hanging on any modern-day hospital wall). So, yes, it is a HIPAA violation.

[RNperdiem, RN]

Life was so much easier before HIPPA.

Nurses used common sense about protecting privacy. Now HIPPA is just one more whip to beat us with and make our jobs harder.

What is so bad about writing DNR? Is is it such a stigma to plan to die only once?

The human mortality rate remains unchanged at 100% DNR status or not.

[rita359]

I'm not sure if I was clear in my post. I'm not against the bracelet, but I think putting DNR on the bracelet is going too far. If the employees of the hospital are not able to learn that blue means 'no code' then they are probably not qualified to start a code.

Putting DNR on the bracelet is also broadcasting the patient's code status decision to visitors.

We train lay people to do CPR. Some people have done CPR in emergency situations by having watched medical shows were CPR was performed and been successful. You can be "john q public" and be qualified to start a code.I do not think putting DNR on the bracelet is broadcasting the code status. It is making certain the person finding the patient lifeless can be certain a code should not be done. That, after all, is the patients wishes.

[Murse901, MSN, RN]

NO NO NO! It isn't! Confidentiality and HIPAA are two seperate issues. Most of the HIPAA act pertains to electronic transmission and storage of protected health information. It deals with how hospitals, md offices, pharmacies et al have to store the information with secure networks and computors, and how it is transmitted, via email, fax, etc.

Just read this response today, and decided to do a little research just to make sure I wasn't being stupid about HIPAA. HIPAA originally only related to electronic storage and transmission of medical records, but has since been amended to include much, much more. Perhaps you could contact your facility's Staff Development Coordinator for a HIPAA refresher. Check out this link from the University of Miami related to Protected Health Information -- http://privacy.med.miami.edu/glossary/xd_protected_health_info.htm

HIPAA regulations define health information as "any information, whether oral or recorded in any form or medium" that

* "is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse"; and

* "relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual."

The bold sections obviously apply to DNR orders, and writing DNR on a bracelet would be a HIPAA violation, because it is health information that is recorded in a publicly viewable location.

[elthia]

Speaking as a daughter, not as a nurse.

When my father was in the hospital, and he was a DNR. If he had been off of his floor for tests and had gone into cardiorespiratory arrest, and someone had performed CPR on him, you better believe there would have been hell to pay.

Stating that he would not have been intubated, or no meds were used, or he was not shocked, would not cut it. The very fact that someone would have performed chest compressions on him after my family went through the heartache and anticipatory grief of making him a DNR would be enough for me to sue everyone who touched him for assault and battery.

We did not decide on a DNR status because my father was terminal. We as a family decided that with liver cancer, hepatomegaly, and mets to his ribcage and sternum, that my father would never survive chest compressions; and the family would not want to live with the image of what CPR would do to him. I am ACLS certified...I had nightmares about this...thankfully my father died peacefully at home on hospice.

Now speaking as a nurse

Temper these feelings with HIPAA. I think a lot of pt's who are DNR, would be a bit upset if you told them, well you would only be DNR on this floor. In XRAY you might have CPR until someone reviews your chart and finds the order. And there is always the chance a housekeeper might find you down and perform CPR, but they'll stop immediately when the nurse tells them to.

I don't think that would fly. On my unit, we have a fast pt turnover, it's a 40 bed unit, and only the charge nurse gets the full pt report. If I'm not charge, and I find a pt lying on the floor that's not mine. I check ABC's, no pulse no respers, I look at the armband. If there is no blue band, I push the code blue button above the bed and start compressions till help arrives. I don't wait on the chart, because if the pt is a full code, waiting to check orders before compressions isn't helping get oxygen to the pt's brain.

I think we have to use some common sense. Using a blue armband with DNR should be ok...afterall the pt has an armband with his/her MRN #, which is also protected information. It's not like we are posting it on the door. It's on the pt's arm.

[elthia]

Then again, we can always go to the source.

(emphasis mine)

Are physicians and doctor's offices prohibited from mantaining patient medical charts at bedside or outside of exam rooms, or from engaging in other customary practices where the potential exists for patient information to be incidentally disclosed to others?

Answer

No. The HIPAA Privacy Rule does not prohibit covered entities from engaging in common and important health care practices; nor does it specify the specific measures that must be applied to protect an individual’s privacy while engaging in these practices. Covered entities must implement reasonable safeguards to protect an individual’s privacy. In addition, covered entities must reasonably restrict how much information is used and disclosed, where appropriate, as well as who within the entity has access to protected health information. Covered entities must evaluate what measures make sense in their environment and tailor their practices and safeguards to their particular circumstances.

For example, the Privacy Rule does not prohibit covered entities from engaging in the following practices, where reasonable precautions have been taken to protect an individual’s privacy:

Maintaining patient charts at bedside or outside of exam rooms, displaying patient names on the outside of patient charts, or displaying patient care signs e.g., “high fall risk” or “diabetic diet”) at patient bedside or at the doors of hospital rooms.

http://www.hhs.gov/hipaafaq/administrative/200.html