HIPAA and personal journals

[newlpn08]

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?

[pagandeva2000, LPN]

It is unfortunate, but the real world sometimes comes down to having to keep some sort of a note for yourself for self preservation. I tend to be too lazy to keep that sort of stuff up, but I know some nurses that do write down the medical record numbers of each patient she was responsible for and would write down something like "chest tube" or something that helped her to identify what the situation was without really writing much.

One in particular, told me she was involved with a situation that later prompted her to keep better track and she even will write down how many "people" (meaning nurses/aides on duty) were "present". I (personally) think that this action is a bit anal for myself (where am I going to put all of that paper first off, and then, I am not going to crowd up my computer with that mess, either), but I do understand why she felt the need to do it and I have don't plan to make her think otherwise.

[medsurgrnco, BSN, RN]

I agree thorough and accurate documentation in the patient chart is the best way to protect yourself. However, who has time to do the overkill documentation that you may not know was needed until after the fact? I used to keep notes on any staff problems & "difficult" patients in case I needed it in my defense later. My pt notes just said things like the date, pt room #, brief details of pt interactions, any details that contributed to difficulty of the shift like the # pts in isolation or admit early in shift. But I've found managers don't listen to me so it didn't seem worth the effort. And my notes weren't detailed enough to help in case of a court case anyway.