An LVN at work (LTC) showed some of us a large notebook that she keeps with info on her patients on a daily basis. She makes notes about them, about things that she's done for them, or conversations with them, changes in their condition, and even has notes from change of shift report written in there. She says that the DON (RN) does the same thing and that's why she does it.
I'm a little unsure if that's a good thing or not. I think that it could be a HIPAA violation, couldn't it? Even if there are no names in there, she probably has room numbers, or bed numbers. While I understand that she thinks she's doing that to cover herself should the need arise, is that necessary? What do you guys think?
Thanks.