How to prove nurse looked up my medical record

[Marmolada]

I was hospitalized in the same hospital that my husband's friend just got a job. She was on training, in completely different ward. She would visit my room often, on her breaks etc. I didn't discuss my condition with her. And I didn't gave her permission to look up my records. One day she visit me in my hospital room and started patronizing me, saying that my calcium levels were really high and my potassium extrey low ( I was in DKA ) and that my kidneys are suffering etc. So in shock I asked her how can she possibly know that. She said my lab tests are very bad and the doctor ( mutual friend , nefrologist from different hospital) said that this indicates possible kidney shutting down. At this point I was so angry and I asked ' how come everybody seen my records but me?' She didn't answer. Instead she looked at my IV bag and ask what is it. I said it's done and for her to not to worry about it. I asked why she knows about my condition but she GOOGLED my IV bag!! And said ' that's what I tought'. I had enough! I said that this is invading my privacy and I do not wish to anyone but doctors to see my files. She did not care! Instead she was patronizing me about my type 1 diabetes! Since she's not my friend, but my husbands friend I was extremely upset and told my husband that this is illegal! He went and checked it, and apparently there's no entry from her login on my charts.

My question is , how could she looked it up without leaving her ID on it. What are other possible ways of finding out what's in my records? ( she knew things that neither me or my husband knew) And how can I prove it? I don't want to get her fired. I want my husband to believe me that she did that. Since there was no proof it seems like she's innocent. But she's not. She did look up my files. She checked my IV bag while I was telling her that I do not wish her to do it. She was working ( on break) , so it has to be some kind of violation. I need to know how she have that, how can I prove it?

[JustBeachyNurse, LPN]

Contact the unit manager or medical records, especially if the records are electronic. Every single access of the medical records must be recorded with an electronic signature. If she accessed your records with her own ID the proof will be there, if she accessed with a trainer's ID or someone else's account that person will have a lot of explaining to do with administration and both your husband's friend and the other employee will be in a lot of hot water.

Penalties are huge for a facility permitting unauthorized access. File a HIPAA complaint with the hospital privacy officer or contact a patient representative. Assuming your statements are all true, she faces fines and sanctions for a HIPAA violation and the facility will likely terminate employment.

Your options: Contact medical records for an audit train of who accessed your medical records and lab results; contact a patient representative for assistance in working with medical records.

You may not want to get her fired but if this is true, this is exactly what she deserves. If she did this to you, she will do it to others. This is a blatant violation of federal law and a classic example of why HIPAA and patient privacy laws were put in place.

Edited to add: How would your husband know if the employee's electronic signature is on your records? Does your husband work in IT, informatics or medical records? Of course she will deny accessing your records. The electronic signature audit trail cannot be deleted.

[NRSKarenRN, BSN, RN]

I have moved your thread to allnurses HIPAA and Nursing Challenges forum.

See our FAQ section at top of section for The answer: Is this a HIPAA violation?.

You should have signed for Notice of Privacy form which will have name of person to contact and request accounting of viewing of your records. While you are still steamed, write out letter about situation including dates + times in question to narrow down chart access. You definitely need to report this situation. I'd start with:

1. Contact Nurse Manager of unit you were on to report situation. Ask for name of Hospital Privacy Officer/Medical Records Manager to send letter requesting accounting of who viewed your chart.

2. Create letter documenting dates and times per above post--give details and send to Privacy officer requesting response in 30 days.

3. If you can not obtain name of unit manager to get info, ask hospital phone operator for above names --if they state can't give out then ask for "Patient Relations Department to file a complaint about Privacy breach".

4. If they have electronic medical record, IT department will be able to conduct chart audit identifying all who accessed your chart.

Info sources:

[h=3]Sanction Guidelines for Privacy and Security Violations[/h]An indispensable source for answers is found here:

HIPAA - Frequently Asked Questions

I'm part of my health systems HIPAA Team + serve as Privacy Officer. Employees have been fired for viewing medical records of patients they are not caring for--including one physician. Hope you can get proper accounting and situation resolved to your satisfaction.

Unresolved? File federal HHS Office of Civil Rights report: How To File a Complaint

[klone, MSN, RN]

JustBeachyNurse said:

Edited to add: How would your husband know if the employee's electronic signature is on your records? Does your husband work in IT, informatics or medical records? Of course she will deny accessing your records. The electronic signature audit trail cannot be deleted.

I was just going to say this. Unless your husband works in the IT department, or risk management, there is NO WAY he would know who has accessed your electronic record.

Call the hospital's risk management department, call the manager of the department you were in, and call the manager of the department this woman works in. What she did was illegal and SO inappropriate.

[elkpark]

I would definitely report this. Just the fact that she has discussed with you information that she couldn't know unless she had accessed your records is enough to get an internal investigation started. Clearly she came into that information somehow. And I agree that, unless your husband is an IT worker at that hospital, there is no way for him to know whether or not she accessed your record.

As for your poll question, I don't think anyone can definitely say "yes" or "no." There is a good chance that, if it is determined she accessed the records of someone she knows personally without authorization, she will get fired. I've seen it happen more than once. However, there are no guarantees.

If you really want to be nasty to her, you can also complain about her directly to the Federal OIG, which is the entity that enforces HIPAA.

Slightly off-topic, but are you going to be addressing with your husband the manifold problems with him having a "friend" who is so nasty and inappropriate to you?

[Marmolada]

Thank you for all answers.

I don't want to get her fired. She has six kids. And I would feel terrible. But at the same time she had no right to see my records.

Apparently my husband checked with the hospital if anyone outside the unit did log into my records. But , it's gonna sound horrible, I don't believe he did. She's an old friend of his and I'm doubting if he ( knowing she can lose job) had done that.

She denied it later on and said that if she did that it would be recorded in the hospital system.

This is why I wondered how else could she have done that.

Mas mentioned in one of the posts above, she could have used trainers ID.

As much as I want to prove that she did it, I hoped there was a way of doing it without possibly causing a job loss.

once again thank you for all answers. I will ask her to tell the truth one more time. If she is going to deny what she said in the room that day, I will contact the unit manager.

[JustBeachyNurse, LPN]

She would be the cause of her termination not you. If she did it to you, she will do it to someone else

[OrganizedChaos, LVN]

I wouldn't feel guilty one bit. She has probably done it before & will do it again. If she's not being honest with you now, she won't be honest with you when you ask her again.

She made her bed, now she has to lay in it.

[futurenurse.26]

This happened to me. My children's father girlfriend looked up my records and discussed my records with someone who came back and told me. I called the HR department at the hospital who directed me to do a complaint. Long story short they traced it bck to her because her login id had been used to view my records more than once. She lied told the I asked her to do so but she was terminated. File a complaint and if in fact this person accessed your file they will be terminated for violation. Of Hippa

[PhillyRNtoBe]

klone said:

I was just going to say this. Unless your husband works in the IT department, or risk management, there is NO WAY he would know who has accessed your electronic record.

Call the hospital's risk management department, call the manager of the department you were in, and call the manager of the department this woman works in. What she did was illegal and SO inappropriate.

Unless she is referring to an account that some major healthcare systems have for patients. For example "MyPennMedicine" for University of Pennsylvania patients. You create an account and you as the patient can access EVERYTHING including logs of who accessed your medical records.

[PhillyRNtoBe]

Marmolada said:

Thank you for all answers.

I don't want to get her fired. She has six kids. And I would feel terrible. But at the same time she had no right to see my records.

Apparently my husband checked with the hospital if anyone outside the unit did log into my records. But , it's gonna sound horrible, I don't believe he did. She's an old friend of his and I'm doubting if he ( knowing she can lose job) had done that.

She denied it later on and said that if she did that it would be recorded in the hospital system.

This is why I wondered how else could she have done that.

Mas mentioned in one of the posts above, she could have used trainers ID.

As much as I want to prove that she did it, I hoped there was a way of doing it without possibly causing a job loss.

once again thank you for all answers. I will ask her to tell the truth one more time. If she is going to deny what she said in the room that day, I will contact the unit manager.

Good for you. It seems like what you want is for her to admit it to your husband at a minimum. Have that one last conversation with her. Tell her you feel uncomfortable with her interfering with your privacy and all you are asking for is for her to admit how she found out your information and that you insist that she tells your husband or you will have to go to the hospital management to find out. Tell her you are giving her a chance to come clean and to you don't want her to lose her job but if she lies about what she said then you will have to report this.

Good luck! This happened to me many years ago but I never reported it. I regret not doing it. Put a stop to it if you can now because it could happen again.

[klone, MSN, RN]

Marmolada said:

Apparently my husband checked with the hospital if anyone outside the unit did log into my records. But , it's gonna sound horrible, I don't believe he did. She's an old friend of his and I'm doubting if he ( knowing she can lose job) had done that.

I don't believe he did this. It's not something that is done easily, and if an inquiry were to be made, it would need to be generated by you. Unless he has a buddy in IT who did it for him under the table, it's a formal process to do this.