HIPAA question

[SneakySnake]

I wanted to make a cheat sheet to use at work. I have no access to a computer at work so I would have to type it up on my home computer. The cheat sheet would have a room number and patient name nothing else. Would this be a HIPPA violation? If that is a violation would using room number and patient initials solve the problem? When at work I would use it for notes but then I would shred it before I left the facility. I have googled this question but I am still confused.

[Chin up]

At my facility, each unit has a sheet printed out for each hall with room numbers, names, and how they take their meds with space to take notes. since I'm new it's been a life saver and a great time management tool. It is not supposed to leave the facility and i put it on a clip board so I can keep it with me and not lose it. I don't think this should be on your PC though. Maybe you can type up one with room numbers and leave room for names and fill them in at work. Make copies for yourself and leave them there at work so you will have a fresh one each shift.

This is the point of my post. She won't have to type one up, they have these at most facilities. They are usually full of pertinent information with room for her own notes. Peace!

[morte, LPN, LVN]

This is the point of my post. She won't have to type one up, they have these at most facilities. They are usually full of pertinent information with room for her own notes. Peace!

I'm thinkin' that she would have seen one by now, if they existed.....I think if the OP made a template of room number with space for notes, took that to work and filled it out with other pertinent info, then copied and left the copies at work, he/she should be fine.....I would think that the institution HAS to have computors in house, and the suggestion might be made to do this on that computor...

[SneakySnake]

They do have census sheets but they are so out of date none of the residents I currently take care of are on them. I made a table with room numbers printed it out and wrote in by had initials and other info. Good idea to make copies at work and stash them somewhere. Thanks all :)

[handyrn]

I may be outdated in my hippa regulations, but I thought that name and room number were NOT hippa violations (as long as the resident doesn't request them to be). You can walk into many nursing homes and there are boards with names and room numbers on them. Any John Doe can walk into these places and get this information. If not, they can walk down the hall and look at a room number and see whose name is on the nameplate.

And now my vent about hippa, a situation that happens frequently. Nursing Home is in a rural town of about 300 people, state surveyors come in and do their survey. Law states that it has to be displayed in a public place. Surveyors comment on the survey states:

Patient A was observed while being administered insulin. Nurse cited for not washing her hands properly. Nurse gave patient insulin injection in the lower abdomen. When surveyor asked why she used a site that was higher than the normal site of injection, nurse states that she was trying to avoid using an already bruised site.

Now, in a rural town of 300 people, everyone knows who is and is not in the nursing home. Because patient A and all the other residents have been residents of the town their whole lives, everyone also knows who is the only diabetic in the facility. Therefore, now anyone from that town now knows who patient A is, and what their abdomen looks like, that they are, indeed, on insulin, etc. Then, down at the local coffee hang out, John Doe states that he was at the facility and read the survey and guess what they found out about Patient A? Now it becomes the talk of the town that Patient A has bruises, is now on insulin, that the surveyors were in her presence, etc. How does this follow the hippa protocol that those same surveyors are making sure we, as employees, follow?

And when the facility gets tagged for something else, John Doe at the coffee shop knows at least one person that the surveyors talked to. And, since it is a little town, now rumors are starting that Patient A, who everyone knows the name of now, probably complained to the surveyors, so now they are labeled as a trouble patient, etc.

Ok, enough of my rant. I think I have worked in rural communities too long!

[debRN0417]

Yeah. That is a problem in small communities. When the 2567 (statement of deficiencies) comes to the facilities, it is a public record. It has (in my state) Residents identified by numbers, however it lists their admission date to the facility and their diagnoses. It says something like: Resident #1 was admitted to the facility on 6/1/11 with the diagnoses of: hypertension, atrial fibrillation...etc.... so in a small town, lots of folks would know when Mary Smith was admitted to the facility, and then they know what the diagnoses are. But no name is identified so the thinking must be that more than one person could have the same admission date and diagnoses, (okay right). It also gives their cognitive status and how much help they need with ADL's. Don't know what to tell you other than that's the way CMS does it.

[SneakySnake]

I may be outdated in my hippa regulations, but I thought that name and room number were NOT hippa violations (as long as the resident doesn't request them to be). You can walk into many nursing homes and there are boards with names and room numbers on them. Any John Doe can walk into these places and get this information. If not, they can walk down the hall and look at a room number and see whose name is on the nameplate.

Ok, enough of my rant. I think I have worked in rural communities too long!

The first part of your statement was also my understanding about hippa but like I said I have been "out of the loop" for a bit.

As for the second portion of your statement AMEN from one rural nurse to another:D

[runnergirl86, BSN, MSN]

You should ask the charge nurse to update your census/roster for you to use. Why do they have that paper available if it is incorrect? That is part of the charge's responsibilities and perhaps you could even suggest working on it with him/her to incorporate your ideas into making it a working document to help your day run more efficiently.

[arabstarRN]

Facility I just left violates HIPPA every shift... they have residents who go behind the nurses station and take paperwork from books/charts/whatever they find, Mar books have had pages pulled out of them, empty med wrappers get taken out of the envelope that the nurses place them in until they can be shredded at end of shift... the residents that take them are psych patients and dont necessarily have the cognitive function to read them and definitely cannot use that information in any way, however, if they leave it on the floor or tucked behind something and the nurses/CNAs can't find it before a visitor does, that is a HIPPA violation in my opinion... Never mind that the nurse does not have time to be chasing down the narcotic books or sheets of individual pieces of paper out of said books every shift.... When your narcotic log book goes missing for 3 hours, kinda slows down your job... and causes issues in narcotic count and proper documentation of narcotics given...

My understanding of HIPPA is ANY information that can identify a patient aside from room number alone, is protected information. Initials are best to use

[yooperPN]

I work midnight's and created my own "spreadsheet" on my home computer to help keep my tasks organized. I have columns for each thing I need to write down, ie: Accuchecks, O2 sats, Drsgs, bed measurements, Temps, etc (I can't remember all the columns I have.. haha!). I have lines under each column for me to write names in, that way nothing is taken home with names on it.

When I give PRN meds that I need to chart in the Kardex, or things I need to add (so and so has a red peri-area, etc), I either write it somewhere on the sheet itself or write in a sticky and put it on the sheet. That way all the things I need to chart, O2's I need to enter into the MAR, etc are in one place. I put this on a clipboard that has an inside clasp that can be closed, so everything is protected when I'm not using the sheet. At the end of my shift, after everything is recorded, I shred everything and don't have to worry about it.

If I were to go on a day or PM shift, I might change the columns to include crush, etc; and just write the names in of who is a crush.