Anyone An Hippa Expert Re: Hospital Staff Access To Charts?? - page 3
When I work at the hospital I sometimes see care partners and unit secretaries reading a patient's H&P. It's not necessarily a patient they're taking care of. Sometimes it seems like it's snooping... Read More
Feb 11, '07When I was a NA in a nursing home we had "cheat sheets" with info on each pt like diet, activity level, special precautions, etc. But never a diagnosis. I didn't really need the diagnosis to take good care of them, but I did find that if I figured out the diagnosis (either by recognizing it myself or a nurse casually mentioning it) it made it much easier to do my job. I also wish I had known what meds my pt was on so I could monitor for things like dizziness or any reaction to the meds that were not normal behavior for that resident. I never ever touched the charts, though. I don't know if I would have been allowed to or not (nurses would criticize me for not always "reading the care plan" but no one ever told me where the care plan was)
As a home health aide I *was* given their diagnosis, which made things much easier for me, especially because I had no one to get report from, no nurse to ask questions of (unless I paged her) and no chart to access.
Feb 11, '07Quote from woohnot due to any power trip here. i know i have no power to anythingthat's not due to hipaa. if you're a healthcare worker involved in their care (it doesn't matter what kind of healthcare worker) you can know the diagnosis (and frankly, need to know if you're going to provide decent care.) i think saying they don't need to know because "they wouldn't understand anyway" is just underestimating their intelligence, and almost a power trip by nurses to withhold information.
i will phrase it this way. i am clearly told by my supervisor and admin. we are not to tell home health aides the dx. of pt. we are to tell them enough pertinent information for them to be able to do their job. they do not need to know dx to do their job. if they are given good information by me regarding care plan individualized for this pt., then dx. is unecessary.
example: "mr.smith" has a dx. of chf. i would tell aide to encourage pt to elevate legs, call rn if pt. has inc. sob, inc. edema to low. ext.., remind pt. to take meds as ordered, prepare meals according to ordered diet, etc. dx. is not needed. on all our pt's if any chest pain or other emergency, they call 911.
most pt's end up telling the aide themselves what their dx. is, that's up to them. the one exception is our hiv pt's because of the discrimination they face. some aides are wonderful. i had one beautiful , smart young lady with a man dying of aids. she knew it and gave him more than anyone could ask for.
there must be a lot of valid reasons they do not tell the dx to aides. i will find out and get back to you the official ones..
Feb 11, '07Quote from tweetytouche tweety! i can see where i come off looking like a jerk, didn't mean it that way i swear!! of course they can read! what i meant is that our charts were rather discombobulated. so the cna's probably wouldn't have been able to decipher what was even current. heck, sometimes we couldn't! no orders at the bedside and half the time, no current orders written in the charts anyway. everything current was in the computer and cna's didn't have computer codes for orders. but that was my particular hospital. i have worked at others where there was stuff at bedside.our cnas are literate and for the most part now how to read things "regular diet", bedrest and such. i'm surprised a cna hasn't read your post and flamed you back because it's a little insulting.
Feb 11, '07Quote from casbeezgirlrntouche tweety! i can see where i come off looking like a jerk, didn't mean it that way i swear!! of course they can read! what i meant is that our charts were rather discombobulated. so the cna's probably wouldn't have been able to decipher what was even current. heck, sometimes we couldn't! no orders at the bedside and half the time, no current orders written in the charts anyway. everything current was in the computer and cna's didn't have computer codes for orders. but that was my particular hospital. i have worked at others where there was stuff at bedside.
thanks for the clarification.
Feb 11, '07Aides need to see the charts to know about these patients. I currently work in an ER and as a tech we are handed the chart to walk a patient back from triage. We ALWAYS read at least the chief complaint to know what we are responsible for. Our manager would have us fired if we routinely walked a chest pain patient back and didn't bother to hook them up to the monitor. Not to mention we are responsible for charting on the chart. (i.e. that we brought the patient back, vital signs, etc.). Now, as for caring for patients on the floor - one floor I worked was kind enough to have a runner that each aide was given that had every patient on the floor listed, their diagnosis, how they got up (i.e. assist x2, ad lib), if they were in isolation, what their diet order is, etc. This system worked wonderfully because the aides were always busy and always helped each other. Rather than having to run down the aide who technically had the patient, each aide knew how a person could get up to assist them to the bathroom. If a patient rang out on the call light wanting a glass of water and you happen to be the aide who answered, you could glance at the sheet and see if they were on a fluid restriction. Everyone still was responsible for their own patient's, but it made it a much more team work type of environment.
Feb 11, '07Quote from TweetyI'm in LTC and that is all in the , the aides' work sheets (prepared daily), and on the daily report sheet from which we chart, and to which the aides have full access.CNA's sometimes need to look into a chart to clarify a diet order, activity status, or something like that. So to say CNA's have no business whatsoever in a chart, doesn't quite ring true.
An example would be, a patient who is NPO is delivered a meal tray. The nurse might not be around, so the CNA checks the orders to see if it's changed. Or a patient during a bath says "the doctor says I can get in a wheelchair and leave the unit". Stuff like that.
Again, there must a "need to know" search for information.
But for the most part CNA's don't need to access too much of the chart.
Feb 11, '07I really want to thank you for all your replies! They have been very helpful. Where I work the aides do get a sheet with diagnosis, diet, code status, ambulation/turn Q/ and a space for comments to them. This form is taped down at the desk face down for privacy but they can flip it up to read it or else make a copy.
Feb 11, '07At one of the LTC fac I worked at there was a CNA doing this instead of working. She had a very poor attitude to begin with and went around talking about the topics that our less than stellar CNAs were discussing with her. I got her out of the charts. She was from an agency and eventually she was gone.
Anybody who spends time to go into the charts and then discusses info that does not directly pertain to their specific job duties should be reported to the person who is resp for their supervision, particularly if they give you a hard time when you point out this beh to them.
Feb 11, '07I applaud CNAs who look for further information in the charts! It shows willingness to learn, self-motivation and professionalism. I am frequently impressed by my coworkers who ask specific questions in regards to dx. and history. And, yes, sometimes they catch things I missed.
That being said I would stop, immediately, any misuse of information or inappropriate discussion.
HIPAA has gray areas......but as I remember it states "healthcare workers have access to any information necessary to do the job at hand". Well, the way I see it moving, feeding, toileting, educating, is part of their job too.
I am disappointed to read some of the insulting responses to this thread.