paranoid nurse

Specialties Geriatric

Published

Specializes in ltc,hospice.

Just wondering if anyone else out there has encountered this. We have a fairly new nurse (to our facility) who works 11-7 and follows me. I found a photocopy of her progress notes in a residents chart. She must have made the copy and forgotten to take it because it was only her entry and subsequent notes had not been written. Anyone ever come across this situation? I am really uncomfortable with this situation. And for one thing have decided to NEVER write out any report for her ( I have done this when I give her verbal report, which I always do)

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Specializes in Pediatrics.

you mean, she photocopies her nurses notes??? [and you fear giving her written report, as she may hold on to it for future use (or legal reasons)? does sound a little weird...

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Specializes in ltc,hospice.
you mean, she photocopies her nurses notes??? hmmm....
yep, she photocopied her notes! i never heard of anyone doing this. and i should add that the notes were about a resident we were having major difficulties with. but what is she doing, keeping charts at home!?!?!?!?!
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Specializes in Pediatrics.
yep, she photocopied her notes! i never heard of anyone doing this. and i should add that the notes were about a resident we were having major difficulties with. but what is she doing, keeping charts at home!?!?!?!?!

i used to do home care, where every sheet had a yellow copy on the back. other nurses suggested i keep them for reference at home. boy, did that get to be a mess!! i have enough of my own garbage, i don't need my work papers on top of that!!!

i wonder what she can do with these papers (say, in a court of law). and is she doing this with every note she writes? i would now think twice before leaving writtent report again. or at least make it really sloppy, so it can hardly be read. :chuckle

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Specializes in Education, Acute, Med/Surg, Tele, etc.

Have you thought of perhaps, asking her?

I have had a copy of nursing notes on situations at my facility that I copied to give to the admin or for reference in say documentation flaws (which is part of my job to oversee if proper documentation is being done), or missed meds or what not (as proof for my write ups or a situation). I have also copied nursing notes to fax to MD's as a way to prove need for a psych eval, change in medication doses, or generalized reports asked for by an MD.

There are many reasons that can be rational, and some that are not and in need of further investigation. She could also not know the ramifications of doing this without just cause and at least much more security about them (I mean leaving them out...ouch! Once my copies are with me they don't leave the teeth of my clipboard till they are in the proper place or shredded!).

I would be interested in why she copied them, but I wouldn't jump to conclusions so fast...could be a rational reason, she doesn't know that she shouldn't do that (and maybe was able to somewhere else to use for a report or info for herself) or something not so confidential...

Either way..asking can really give clues to your next course of action....

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HIPAA violation if she takes these home??

I'd ask her what was up.

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I have copied certain things in certain situations, so I would have proof of something to back me up if I needed it, which so far I never have. But I don't do it routinely, and I don't take them home. Each nurse at my job has a file cabinet drawer where she can keep things, blank forms, etc, and I put any copies I've made in there in a folder. They never leave the facility. And if the situaton resolves itself I will shred anything I've copied.

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It does sound a bit odd. I recall, however, working in a group home a couple years ago where one of the residents was simply going beserk 24/7 - violent, self abusive, wired to the hilt, a true danger to everyone and everything around him. Yet the QMRP at the time, a person I never trusted as far as I could throw him to begin with, flat out refused to have him taken to the ER or psych ward for evaluation, I suspected because of money (the company has to pay for hospitalizations). We must have written AT LEAST 75 incident reports! It got to where everyone from the team manager on down suspected the QMRP of "disposing" of the IR's, and so we ended up copying them if it ever came back on us. One of the shift supervisors, a person of considerable integrity, kept them in a safe place. Alas, the QMRP was able to claim the guardian deep-sixed the request for hospitalization (I never believed that), and so things kept on the way they were. :angryfire :angryfire :crying2: :crying2:

What that Q did to all of us was just damned unforgiveable, IMO. :angryfire I'm glad he's gone now, even tho I left the company before he did.

Tom

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Perhaps she doesn't trust your administration, particularly as you say it is about a resident with whom you are having difficulties. I have worked places where I couldn't trust the leadership not to alter documentation.

Any notes you keep at home are subject to subpoena in a legal case, if the lawyers find out you have them. I worked with a nurse who wrote incredibly detailed shift report notes (which is why I did most of the work on the shift; I didn't have time for that!) and filed them all away at home. Heaven help you if your private notes don't exactly match the facility records.

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Heaven help you if your private notes don't exactly match the facility records.

Or maybe Heaven help the facility. It could go either way.

That's why in some situations I've sort of backed myself up.

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Specializes in LTC, ER, ICU, Psych, Med-surg...etc....
HIPAA violation if she takes these home??

I'd ask her what was up.

I do believe that this is a HIPPA violation. You cannot take confidential info out of a facility.

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