Keeping a skills journal

[Guest309671]

I am a new grad nurse in my first year working as an RN. I learn a great deal every day, and want to track my progress and accomplishments. I want to be able to look back a year from now, whether I'm in a yearly review at my current position or interviewing for a new opportunity, and discuss specific accomplishments, strengths, and areas for improvement.

So, for the past month or I've been writing a few short sentences after every shift about what I learned that day. We're talking paper/pen/notebook journal. For example, "Learned how to administer [antibiotic] I'm" or "Received positive feedback about [thing]." It's been helpful in internalizing a sense of competency and accomplishment, and combating that sense of Impostor Syndrome that new grads tend to feel.

However, I want to make sure I'm on the right side of the law by doing this. I've been reading threads on here about the legality and ethics of keeping a journal as a nurse, and it sounds like there's issues with HIPAA and issues with journals being called into evidence in legal cases.

Could a skills journal like this come back to bite me? I wouldn't want my reflections on my skills, obstacles, or shortcomings to become legal fodder.

[JKL33]

Absolutely okay.

I think this is a great way to 1) document your nursing career in general and 2) allow for reflection about your learning process over time.

I have never had to defend myself in court or been in trouble for a HIPAA violation, so I will only share with you what I've been taught and others can correct my information as needed.

There are at least a couple of types of personal writing that could, in some extreme circumstance, cause a problem. Examples:

-You write in great detail about your patients and then lose the journal which has your name somewhere in it and also a bunch of PHI about specific patients (HIPAA concern).

-You keep lots of notes about specific patient care which you didn't document in the patient's actual record. These types of things are discoverable in legal proceedings and may just as well work against you as for you. So they are generally to be avoided. Anything that is directly relevant to the patient's care should, instead, be documented in the legal record (chart), and if you ever have to testify you will adhere strictly to what you've already documented.

ALSO

I don't want you to get lax about privacy issues, but I do think it's only fair that nurses understand HIPAA separate from their employer's "privacy practices" and other relevant policies. So I'll tell you this: When you hear stories about someone who gets on social media and posts, "I had an absolutely terrible day today" and then their employer disciplines them for that, that is NOT a "HIPAA" violation. It is something that peeved the employer because it could be said to make them look bad. They like to come down on this type of action so they can keep everyone walking a line.

They have spent so much time trying to scare employees with their own public relations wishes and "privacy practices" by conflating them with HIPAA that now some people really don't understand what HIPAA is about. Writing in your own private journal that you learned how to start and IV or you feel really good about getting an IV on the first try in _______________ stressful situation is most certainly not a HIPAA violation. Neither is saying that you had a wonderful, exellent, terrifying, or sad situation at work. (Now, putting those things on social media is stupid, but that's not what your question was about.)

You can keep your journal. Be reasonable and keep it to yourself (because people love to police one another). No one is coming to search your home to see if your personal thoughts about your own nursing progression put to paper could somehow constitue a HIPAA violation. :)

Best wishes with your career ~

[Davey Do]

JKL33 said:

You can keep your journal. Be reasonable and keep it to yourself (because people love to police one another).

Journaling is a great process, Tomato Soup RN ! I've got journals going back over 40 years and can tell you the process is extremely rewarding.

The product is relative. I find my old journals pretty pretty boring. It's kind of neat, however, to read what I thought about early in my nursing career, a young man in his twenties who is now in his sixties. And then on to different jobs and positions and people.

Good luck to you, Tomato Soup RN !