Worksheets--do you keep?

Nurses General Nursing

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Specializes in Big Variety.

The papers that you used during your shift, with your notes on it, do you keep them?

Is it dangerous to keep them?

Or do you feel that if something happens the worksheet will jog your memory, just in case?

Specializes in Community, OB, Nursery.

I don't usually, for a couple reasons.

1) No guarantee that I'll even have the same group of patients back.

2) I like to start every day w/ a new sheet, because at the end of my shift, my paper is so messy and folded, things scratched out, and what-have-you, that it's just not worth salvaging.

3) Treatments change, med times change, and pt status may have changed too.

A lot of my coworkers do keep/use their worksheets from previous shifts though. You do have to be careful, however, if you're talking about taking said sheets home. That can be dangerous in terms of HIPAA.

Specializes in Hospital Education Coordinator.

I think this might be a HIPAA violation as well, the same as carrying home copies of labs, etc. We are supposed to document in the chart so that a clear picture will be there to remind us even years later. (HA!)

What exactly do you mean by "something happens"?

Are you asking if maybe it might be useful to have you report sheet if you get involved in a lawsuit?

I don't worry about that. I toss my report sheet in the secure bin that goes to the paper shredders after my shift is done.

Specializes in Acute Care, Rehab, Palliative.

Mine goes in the shredder bin as well.

Specializes in ED, Hyperbarics, EMS.

My opinion is you should discard (appropriately) them unless you have a use for them, and once you no longer have them, discard them. If you keep some (for reference sake, or to "jog your memory") but don't keep them all, you may have a problem later on if you are sued for malpractice or subpoenaed for another purpose. If you have it, it could become evidence (and could either hurt or help you, but I personally bet it would hurt more then help,) and if you don't (because it's not one of the ones you chose to kept) they will use that as "evidence" that you are trying to hide something. Therefore, it's better to discard them all, and simply say "I may keep notes for my own personal use during a shift, but once my shift is over or care is complete, I log those notes into the computer and discard my personal notes in the shredder. Everything that was on my personal notes is reflected in my formal care notes." At least then you're only being held to one standard, and not whatever standard a trial lawyer wants to try to make up regarding your own personal notes.

I am not a lawyer. It was just something I've been told in the past, which made sense to me.

Specializes in Gerontology.

I put mine in the shredder at the end of the shift. That way, I don't risk breaching confidentiality by bringing home something with a patient's name on it.

I also do not pass my sheet on to someone the next shift because I have no control over it once it leaves my hands. I've annoyed some people by doing this, but I don't care. Our worksheets are printed from the computer and have my neumonic on it. If someone else leaves it lieing aroung, I'm the one who gets blamed.

I have also heard that if you keep them, they can be used in the event of a law suit. Of course, my hand writing is so bad, they have to bring in a code-breaker to read it!

I keep mine. I NEVER TAKE THEM HOME. I store them at work in my locker in a folder. I was told that if they are kept at work, they can be used as a legal document. Remember in nursing school we were told to keep a diary, this serves as the same purpose but it must never leave the job site! Think about it, it has vitals, meds,times, notes, etc... What a perfect diary!

I keep mine. I NEVER TAKE THEM HOME. I store them at work in my locker in a folder. I was told that if they are kept at work, they can be used as a legal document. Remember in nursing school we were told to keep a diary, this serves as the same purpose but it must never leave the job site! Think about it, it has vitals, meds,times, notes, etc... What a perfect diary!

That's what the chart is for. If it's important enough to need to be written down forever, it should be in the chart.

Yes, I know that is what the chart is for but I wonder if I will be able to see the chart when or if I end up in court. Our charting is computerized.

Specializes in ED, Hyperbarics, EMS.
Yes, I know that is what the chart is for but I wonder if I will be able to see the chart when or if I end up in court. Our charting is computerized.
You will absolutely be able to see your chart. If your are the defendant or you are testifying for the defendant (and he has a decent lawyer, which I hope to God he does) they should make sure that you see the chart prior to testifying. Not that it will help you that much, 'cuz you would be amazed at how a lawyer can twist your words. If it weren't so evil sometimes, it would be amazing.

It was advised notes or a journal can be subpoenaed for a court case in the legal column of one of the nursing journals. All of one's notes or all of one's journal, not just extracted notes pertaining to the case at hand. Some nurses journal and use this info with their therapist. So, in this instance, one should be careful what one puts in their journal. This was discussed with my attorneys when they asked if I had notes when preparing for my deposition. At the deposition, copies of my charting were the focus of the deposition. The opposing attorney went over my charting, line by line. I was sweating throughout. When they tell you in school to chart for the courtroom, they know what they are talking about.

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