LVN keeps personal notes about patients

[VegGal]

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.

[Anonymous865]

I suspect the organization's lawyers would not be happy about that nurse keeping a personal record of his/her patients.

Everywhere I have worked the organization's lawyers emphasized that there should be "a single source of truth."

We were told not to keep personal records, not to keep information in email, and not to keep files on a company PC.

The only place we could keep information was in the official record.

They explained that if a subpoena is issued, the lawyers are required to provide ALL documents related. If the lawyers did not know about for example a personal journal or a brain sheet in someone's locker, they would not provide it. If it were ever discovered that they didn't provide a document, it could be really bad for the organization and the lawyers.

They also explained it is extremely costly for the organization to have to search for "other" records.

[Kooky Korky, BSN, RN]

Encourage the LVN to ask her malpractice insurance provider if keeping a journal of conversations with patients, changes in their medical condition and change of shift notes, is violating patient confidentiality and privacy and if the journal can be subpoenaed in court.

The journal contains confidential health information without the informed consent of the patient

The journal contains conversations and unique medical information that may make it possible for a patient or colleagues to identify a patient

The journal is not stored in a secured manner

A malpractice lawyer can clarify some of misconceptions that the LVN has about keeping a journal, it is not as harmless as she believes.

Is pt consent necessary for this purpose?

How do we know where or how it is stored?

Where does the author find the time?

[nursel56]

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.

My first thought would be to ask the DON (RN) why she does it, since the stated reason the LVN does it is because the DON does it.

If the reason to do that is to cover yourself in case of a potential lawsuit, and the patient's name is omitted, it would seem impractical to present the notebook as evidence of the care you provided to a specific patient.

I would start keeping notes in a case where there is a dispute brewing, but I would keep it to myself. Hopefully these are not a frequent occurrence.

If the journal is meant to gain insight or reference learning experiences, there would be no reason for anyone to know it exists at all.

[Guest1025459]

Bump.

Before my dad passed away, he was heavily into cryptography.

If I was currently a nurse, and outside of work had the desire to document something to cover my a$$ years down the line, I'd probably consider doing this.

I'm not trying to play devils advocate or advocate doing something illegal, but if someone is that paranoid about anything, including nursing, you can hypothetically do this...

Physical devices (notebooks, keys to a safe, keyfiles maybe, etc...anything physical) is NOT covered under the 5th amendment. You would have to give up your journal notebook in court.

Anything which is considered entropy (in your head, literally) is covered under the fifth amendment and self incrimination.

So if you were taking notes about patients on an old desktop or laptop laying around, booted into TAILS on a live DVD, then made word documents on said patients.

Then you proceed to save them on a flash drive protected by LUKS or VeraCrypt, etc with a very strong password, how can anyone find out?

Second, if you are using a live Linux distro, the only data that is ever saved, is in RAM. The only security flaw, that is in the known world is what's known as a stoned boot attack. Which the risk goes after 5 minutes from the time you shut the device off, as the RAM has now cleared.

I'm assuming HIPAA violations would be a criminal matter, not a civil matter. So if your computers were seized, they find the flash drive, and there's no way to tell if it's encrypted then how do you get the blame?

Shut up, don't disclose your passwords, and for the Love of God, don't make your password "Hi I'm an RN" Which according to a password checker, takes two weeks to crack. Probably less

I suppose if you are borderline paranoid and psychotic, or need to hide the nuclear launch codes a patient gave you, a VeraCrypt hidden volume hidden inside a LUKS volume takes the cake.

[Guest1025459]

I was advised to NOT keep shift sheets or notes because in the event of a lawsuit, if it was discovered that a nurse had kept these then they would all be discoverable/subpoenaed. That was before HIPAA though. Now I am wondering if that was good or bad advice.

The post I'm referring to from my last post

[ruby_jane, BSN, RN]

I don't do this daily but if something unusual happens and I really want to remember it, and there's no way to chart it, I have an 8 1/2 x 11 notepad that I write these things on. Usually it has to do with interactions with my supervisor who notoriously doesn't want to put anything in email. When I email something and I get a verbal answer back, I'll just write it down. It's helped me more than once.

[SmilingBluEyes]

IF you're gonna keep a personal journal or diary, don't be stupid like this LPN. NEVER EVER share this fact. Such documents are discoverable if known. It's beyond dumb to tell others you journal your job.