Is looking at a patient's chart on your floor a HIPAA violation?

Nurses HIPAA

Published

Specializes in Nursing Student.

I'm in my last semester of an ADN program, and I'm too afraid to ask my instructors because it's probably something I should already know. I realize looking at patient charts is a violation if they aren't assigned to you, but what if they're on the unit you work on? 

I've noticed my clinical instructors are constantly looking through patient charts, which obviously makes sense because they need to know which patients can be safely placed with students. However, what if you're working on your unit and you have to look up information for a patient that isn't yours? For example, what if the assigned nurse is not available and you need to see if a patient has any precautions not readily apparent? Maybe the patient needs help that cannot be postponed until the nurse comes back, but certain relevant interventions may be contraindicated?

I'm not asking to look at their charts out of curiosity (I wouldn't risk my license over that), but out of safety for me and/or the patient. 

Specializes in Hospice.

My thought process has always been that if the patient is on a unit which I am working on and my assistance/ care with a patient for whom I am not specifically assigned is needed, then it is appropriate to look in the chart to obtain or verify the necessary information. For just the reasons you mentioned - safety, appropriateness of interventions. We are expected to provide safe, appropriate care and need information to do so. On example of this would be a patient found pulseless/ apneic and the assigned nurse not immediately available. I would need to know code status to determine how to proceed. 

We get education regarding patient privacy and this is crucial for many reasons. We don't always get the education explaining when it is appropriate (and necessary) to look in patient charts for patients who are not exclusively assigned to us.

I'm currently traveling to a very small rural hospital. 
we all get report in huddle on all of the patients, because at any point during the day you may be helping someone to the bathroom, passing meds, or doing any one of 6000 other things that require you to know about the patient. 
In big hospitals you get report on your patients only usually, so if you're trying to help with vitals or give meds or do a discharge for a busy nurse or get someone to the bathroom or tell the rounding specialist some obscure lab value, you're gonna need to get in the chart.

HIPAA allows you to view a chart if you have any work related reason to need the information. So when 107's nephew comes out and says she has to pee - I need to know if and how she ambulates, if I need a urine sample, if they're on chemo meds that require precautions when I flush the toilet, if they need orthostatic vitals that I can knock out while I'm there, etc...

Now if they need help with the TV or closing the blinds, I've got no way to justify opening that chart.

PrettyPeachyRN said:

I realize looking at patient charts is a violation if they aren't assigned to you [...]

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That is not correct.

Much better way to think of it is whether or not you have a legitimate need to know. Obviously one will have a legitimate need to know if the patient is directly assigned to you, but the opposite is not true (that if the patient is not specifically assigned to you then there can be no need to know).

You gave examples of why/how this is so in your OP. For example, you very frequently will be expected to help patients who are not specifically assigned to you as the primary RN.

Please continue to learn as much as you can about HIPAA. There seems to be a great deal of misunderstanding about it among nurses. Employers have worsened the misunderstandings; they have no interest in nuance (or common sense, seemingly), they just want to make hard and fast blanket-type rules to protect themselves.

 

Specializes in Nursing Student.
JKL33 said:

There seems to be a great deal of misunderstanding about it among nurses. Employers have worsened the misunderstandings; they have no interest in nuance

Yes, I'm starting to get an inkling of this, unfortunately. Thanks for the clarification.

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