Does carry a personal nursing journal...

Nurses General Nursing

Published

Does anyone carry a personal nursing journal that lists the things you did for a patient on a daily basis? I know of several nurses where I work that do this. They even write things the supervisor tells them to do and what other co-workers say (if they feel the need). They carry that little notebook everywhere. I don't know, I just feel that's a little paranoid and over the top. But...in a legal stand point, would that hold up in court if something went wrong? Should I also be carrying a little notebook everywhere? :confused:

Up Vote Up Vote ×
Specializes in tele, oncology.

I often don't even have time to do my charting in a timely manner, I can't imagine having a job where I have the leisure to make personal notations about everything!

There have been times when situations have arisen where I briefly reiterated what I've done for a patient for personal back up, identified by pt's initials and date, just in case. But those circumstances are extremely rare and involved God-awful patients/family members/MD decisions where I thought that litigation was a realistic fear.

Up Vote Up Vote ×
I often don't even have time to do my charting in a timely manner, I can't imagine having a job where I have the leisure to make personal notations about everything!

There have been times when situations have arisen where I briefly reiterated what I've done for a patient for personal back up, identified by pt's initials and date, just in case. But those circumstances are extremely rare and involved God-awful patients/family members/MD decisions where I thought that litigation was a realistic fear.

ditto this one

Up Vote Up Vote ×
Specializes in ICU.

just came from a conference on legal issues involving nursing.....there it was CLEARLY stated that little notebooks or personal renditions of events written down and stuffed under the microwave at home can be and legally have to be made public to any lawyer bringing action against the institution....a he said, she said account actually gives a road map to a prosacuting lawyer and can be used against you, muddles the facts and makes it harder for a defending lawyer to defend the case........not a good idea. :smokin:

Up Vote Up Vote ×
Specializes in ED, ICU, PSYCH, PP, CEN.

On my calendar I put what rooms I had or what job I had each shift. In the ER you may end up giving 1 med to a pt you will have nothing to do with but your name is still on the chart.

This way I know if I was the primary nurse, or room float or triage etc. That way they can't come back to me and say you didn't do right by this pt. (has happened and I couldn't remember if I was float or primary and they don't keep track of this)

Some shifts I can end up changing roles every 2 hours.

Up Vote Up Vote ×

I would not let anyone see such a journal at work. One does not want it known that they do this. In the unfortunate instance where there is a lawsuit, if it comes out that the nurse keeps a journal, the entire journal can be subpoenaed, not just the pages that refer to the patient involved in the litigation. I saw this advice in a nursing magazine and had occasion to refer to it in the lawsuit that I was involved in. Just a good rule of thumb, journal if you must, but keep the fact that you journal to yourself.

Up Vote Up Vote ×
Specializes in LTC, ER.

I agree w/the posters who warn against personal documentation d/t legal issues. I attended a legal documentation seminar hosted by a nurse attorney who said that any personal documentation has to be declared and will be subpoenaed and will almost certainly work against you. That being said, I do keep copies of certain documents that I am concerned may "disappear" when I have had unusual problems at work. I have worked in the kind of LTCs where nurses notes have been rewritten, narc sheets changed, etc.

Up Vote Up Vote ×
Specializes in ER,ICU,L+D,OR.
Does anyone carry a personal nursing journal that lists the things you did for a patient on a daily basis? I know of several nurses where I work that do this. They even write things the supervisor tells them to do and what other co-workers say (if they feel the need). They carry that little notebook everywhere. I don't know, I just feel that's a little paranoid and over the top. But...in a legal stand point, would that hold up in court if something went wrong? Should I also be carrying a little notebook everywhere? :confused:

I never have nor will I carry a nursing journal. One, I have a fantastic life and I love living it fully. Two, I can not see any reason to have such a journal, that is what nurses notes are for. They are legal. Nor would I track what a supervisor tells me, or what co workers say. I can not see any justification to do so. I do not know about paranoid, maybe obsessive compulsive. I do know a few nurses that do keep a work journal. I have never been able to understand why.

I do have a diary that I keep at home, but that is of a much more personal nature. Life, Loves, Activities. Plans, Goals, hopes, dreams. I also have a hope chest. I also have my mothers and my grandmothers hope chests. A lot of family history there.

Up Vote Up Vote ×
I never have nor will I carry a nursing journal. One, I have a fantastic life and I love living it fully. Two, I can not see any reason to have such a journal, that is what nurses notes are for. They are legal. Nor would I track what a supervisor tells me, or what co workers say. I can not see any justification to do so. I do not know about paranoid, maybe obsessive compulsive. I do know a few nurses that do keep a work journal. I have never been able to understand why.

I do have a diary that I keep at home, but that is of a much more personal nature. Life, Loves, Activities. Plans, Goals, hopes, dreams. I also have a hope chest. I also have my mothers and my grandmothers hope chests. A lot of family history there.

DITTO to that.

as far as the what co-workers say crap- sounds kind of petty to me. Of course I could have just taken it out of context. It is early after all.

Up Vote Up Vote ×

If you choose to keep a journal, I wouldn't carry it to work or tell anyone that you have it. If you lose it at work that could be potentially very damaging.

Up Vote Up Vote ×
just came from a conference on legal issues involving nursing.....there it was CLEARLY stated that little notebooks or personal renditions of events written down and stuffed under the microwave at home can be and legally have to be made public to any lawyer bringing action against the institution....a he said, she said account actually gives a road map to a prosacuting lawyer and can be used against you, muddles the facts and makes it harder for a defending lawyer to defend the case........not a good idea. :smokin:

People need to think about things like this when scare tactics are used to intimidate nurses into NOT taking measures to defend themselves.

Here is a fact: You will never, be legally forced to provide a document that no one knows is in existance and if you deny it's existance.

That's why you don't tell anyone...and that means no one.

Yeah...someone will say, "OH THAT'S PERJURY!"...Well, perjury also has to be proven in court...just like anything else...and if NO ONE knows you keep a journal, then they can't prove it.

I would love for someone to show a link/court case/etc for a nurse who had a search warrant issued against her "just to see" if she had a journal at home without any evidence that she actually had one to start with or even a rumor that she kept one.

You won't find it because it doesn't exist. You can only get those from a court via "probable cause".

As long as attorney's keep doing scare tactics like this so nurses will be in a LESSER position to defend themselves, that nurse will always be vulnerable.

Up Vote Up Vote ×
Specializes in ER,ICU,L+D,OR.
If you choose to keep a journal, I wouldn't carry it to work or tell anyone that you have it. If you lose it at work that could be potentially very damaging.

Yes, Don't you watch the Starter Wife on TV and see what happened when she lost her journal.

Up Vote Up Vote ×
+ Add a Comment