Is it wrong for a nurse to look at charts of patients not under their care?

  1. I'm a newer nurse (less than 2 years' experience). When I was in school, instructors would occasionally open up patients' charts for the purposes of education. I am wondering whether it is a violation to look at the charts of patients who are not assigned to you (or no longer assigned to you).

    For my own patients, I feel it is very beneficial for me to review consulted physicians' notes, see what has changed in the plan of care and why, and sometimes even to go further back and read the admission notes from the EC (how did the patient present and how did that influence decision-making, etc). If there is a patient on the unit whose case is unusual, is it okay to look at vital signs, read notes, and look at medications for the purpose of "putting it all together?" Is it okay, if you see that your patient from the other day has been transferred to the ICU, to look and see what happened, what s/s were observed and how action was taken?

    I know that even if intentions are good, and this information is used for nothing more than my own knowledge bank, it may still be viewed as a privacy violation because it is not something I "need to know." To clarify, I absolutely would not consider it okay to view charts of patients from other units who had not ever been assigned to me, or to look at charts of people I knew out of curiosity.

    Thoughts?
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    About michigannurse2014, RN

    Joined: May '16; Posts: 6; Likes: 6
    Registered Nurse; from US
    Specialty: 2 year(s) of experience in Psychiatric, Medical/Surgical

    8 Comments

  3. by   JustBeachyNurse
    No it's a HIPAA violation. If you want follow up make arrangements with nursing education or your manager. Doing this on your own especially a patient that is not under your care that is "unusual". IT will flag your account very quickly and you be called to management to explain your unauthorized access to confidential protected health information. Is your independent knowledge quest worth risking your job?
  4. by   AllOfMyWat
    You know the answer to the question. You know it isn't okay. Also, if I worked with you, I would resent if you're flipping through charts of non-patients and then need help because of a time crunch. I actually would probably turn you down for nonessential assistance.
  5. by   RiskManager
    It is most definitely not OK. Unless you have a legitimate payment, treatment or operations reason to review a chart, you should stay out of it. This is a HIPAA violation and you could be subject to discipline for this, in addition to having to talk to Compliance, Privacy, or Risk, all of whom will have a frowny face.
  6. by   CrunchRN
    Oh dear. You need to ask? Not to be flippant, but you should know the answer. Don't open yourself up to that kind of censure.
  7. by   Meriwhen
    Yes, it's wrong. While I can understand your curiosity and desire to learn, this is a HIPAA violation if you do not have a legitimate reason to be in their chart.

    Being fired for a HIPAA violation is incredibly tough to bounce back from. Is it really worth the risk?
  8. by   michigannurse2014
    Thanks for the replies! I had a feeling my gut instinct was right, but I appreciate others' input.
  9. by   NICUismylife
    You mention going back and reading admission notes and such. That is. 100% okay for a pt assigned to you. You can access their entire history and record and you should in order to provide the best care. But once that pt is no longer assigned to you, you can't access their file to check on their progress. Just wanted to clarify that it's ok to look at complete hx when under your care.
  10. by   akulahawkRN
    For patients that are directly under your care, you can absolutely access all aspects of the chart that pertains to your ability to provide care for them. I generally routinely look back at my patient's previous physician notes to get a better idea about what may be going on with my patient during this current visit. Once that patient is discharged out of my care, my ability to go back into that chart is very limited and would only be for the purpose of completing the charting of my care during that visit.

    I currently work in the ED and everyone has access to every chart of the patient there. That being said, the reason we have this ability is so that I can hop over, do a task for my co-worker and chart that task that I have done. Since that's not my primary patient, I do not have the legal right to browse all over that patient's chart. My access rights are only for the purpose of accomplishing and documenting a given task.

    One interesting thing we do is audit our charts for completness. The fact that we have completely unfettered access to a chart actually helps us do this task but we also fill out a report that includes our ID so that later we can prove that we had the legal right to access that chart. Our computer system does make a note of who accesses patient charts so that helps greatly with HIPAA issues later.

    Outside of those purposes, I have absolutely zero reason to be in anybody's chart and getting into a chart is a HIPAA violation and is grounds for disciplinary action, up to and including employment termination.

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