HIPAA and personal journals

Nurses General Nursing

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I would like to start a journal as I am going through clinicals, and starting out on my nursing career. I do not wish to violate HIPAA, so I was wondering how much information you put in your personal journals.

I would like to put date/time and whether I was in ER or CCU, and I would like to write down what I did. How much would you write? I plan on not writing down pt name, age or diagnosis, just general interaction. What I found interesting etc. If there is no age, name, or other identifying things, would there be a HIPAA violation? What do you think? What do you write?

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Specializes in ICU, Emergency Department.

I would think as long as you don't post hospital name, any patient information, and any info that could give away where you were (like town names or anything) it wouldn't be a HIPAA violation.. but I could be wrong, and I'd wait for more responses before going ahead and doing so.

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There could still be some identifying information so you need to be careful. It depends on a number of things but a big factor would be the circumstances and size of your area. If you add date and it is something out of the ordinary (for that area) like the interaction between you and a mother losing a child in a car wreck that could be considered identifying information.

For the most part if you would put something like this I would see no problem with it.

3/20 CCU

Inserted NG tube

Ng feedings x2

THIS IS JUST AN EXAMPLE. Say for instance we had a nurse come on here and say "I took care of a patient exposed to @@@@@@ (random biological agent) this past month and this is what happened." Despite having so many members and being read around the world that still likely would be identifying information.

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Specializes in NICU.

If you're going to keep one, I sure wouldn't mention it. I think if you are sued and they are aware you have kept any kind of info in your journal it can be admitted in court. Just something to think about...

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I never would have thought about not mentioning keeping a journal because it could be used in court. Thank you for bringing that up. If I start writing a journal, I will keep my journal a secret.

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We were required to keep weekly journals about our clinical experiences. They were kept in our folders and used to help us see how we were progressing. It also helped the instructors with grading.

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Specializes in neuro, ICU/CCU, tropical medicine.
If you're going to keep one, I sure wouldn't mention it. I think if you are sued and they are aware you have kept any kind of info in your journal it can be admitted in court. Just something to think about...

I remember hearing that in an orientation session - that notes nurses keep become discoverable.

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Specializes in neuro, ICU/CCU, tropical medicine.
If I start writing a journal, I will keep my journal a secret.

One word: perjury. If you deny it's existence under oath you've broken the law.

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I personally, plan to keep a journal when I start nursing, and I plan to put anything I wish in it.

I also, don't plan on telling a single person, including my husband, that I am even keeping one.

To me, the purpose of it is to refresh your personal memory of the account, should the need arise, and you are going to need to put alot more information than J.L. or M.N. in it to remember.

I just don't see why the fact you have a journal, ever needs to be disclosed.

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Specializes in Cardiothoracic Transplant Telemetry.
i personally, plan to keep a journal when i start nursing, and i plan to put anything i wish in it.

i also, don't plan on telling a single person, including my husband, that i am even keeping one.

to me, the purpose of it is to refresh your personal memory of the account, should the need arise, and you are going to need to put alot more information than j.l. or m.n. in it to remember.

i just don't see why the fact you have a journal, ever needs to be disclosed.

if you are ever called into court and need to use that information, how are you going to be able to explain your super-memory of the details of a patient interaction that occured 5 years ago?

any personal notes that you keep about your patients, even if you just keep your brain sheets from each shift, are discoverable. deny their existence and have a super-memory? risk being thought that you are lying either about what you remember or about not having kept notes.

as always, the best defense against a law suit is accurate and detailed charting. on the stand it will always be acceptable to say that you don't recall, and ask to refer to your charting for the shift to refresh your memory.

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Specializes in PACU.

I wouldn't be quite as anal as some here propose. I would obviously not put anything that readily identifies the patient, but other than that I'd consider anything fair game. I wouldn't tell anyone about it and I'd never refer to it for legal purposes. If asked about it, I'd just have a lapse of memory (as I'm prone to do) and fail to recall its existence or state that I lost it in a tragic boating accident. Obviously, you'd need to be a LOT more careful with something that you intended to publish or post online.

That all said, I am way too lazy to write a journal or diary unless coerced to do so by an instructor.:stone

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Specializes in Community Health, Med-Surg, Home Health.
If you're going to keep one, I sure wouldn't mention it. I think if you are sued and they are aware you have kept any kind of info in your journal it can be admitted in court. Just something to think about...

That is basically the bottom line, to me...just don't tell anyone. And, to be sure, I probably would not put specific dates, I may say "first day on clinical site for med surg; 5th day at the clinic" and no names or identifying information.

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