Learning from a computer chart vs. a written chart.

[dudette10, MSN, RN]

Students and nurses alike know that students go through charts for care plans, case studies, and the like. This is obviously not patient care, but learning. It's a long-standing common practice in nursing schools.

In addition, we all know that when an individual student is assigned an interesting case that we all can learn from, the clinical instructor will sometimes have us gather together to all look at the written chart, along with an explanation of what was going on with the patient. It's a learning experience.

The following explanation is going to be vague, but the details of the patient aren't important to my question. Please bear with me.

I was once on a rotation in which the written chart of a patient did not have information that was necessary for me to understand the whole picture of the health complication that had occurred. A nurse, who had been a member of the team (but not the main nurse) for the patient on the previous day, had some extra time, so she graciously was doing some teaching by showing me the chart on the computer, in particular the nurse's notes to illustrate another nurse's observations about this health complication, the timing, her assessments, her interventions, her collaborations. Essentially, the chart was helping me understand what a nurse does in this situation, in addition to the nurse's explanatory narrative.

Someone came in and warned the nurse that looking at the patient's computer chart wasn't appropriate. My nurse logged off, gave an explanation to why she was showing me the computer charting, and then both of them continued to teach me about this complication because both of them knew about the particulars of the previous day.

I'm not saying anything negative about the person who warned the nurse. She was also a very helpful person in helping me understand what a nurse does in a complication like this. I learned a lot that day from both of them.

But, the whole incident got me to thinking.

Why in the world is it okay to go over written charts, share written charts, share verbal information, etc. for students who are NOT doing the review for patient care reasons, but when the computer is involved, people get a bit paranoid? Did the nurse really do something wrong?

[ShantheRN, BSN, RN]

I'm curious about any answers from seasoned nurses myself....because it doesn't make sense that you can't look at one part of the chart but another is okay. Regardless of what you were looking at, it was to ensure proper care was given.

note: seasoned nurse=anyone that's graduated and passed boards, because that puts you ahead of me!

[llg, PhD, RN]

The answer is that there is no real difference in looking at computer charts vs. paper charts. The act is equally right or wrong regardless of the format. However, the switch to electronic charting has heightened the sense of security/insecurity of those records and brought the question of the appropriateness of such sharing of patient information unnecessarily.

So ... if it's wrong with the computer chart, it was wrong with the paper chart, too. If it's OK with one, it is OK with the other. It's just that the paper charts were more difficult to access physically and the common practices associated with the use of the paper chart were established before there was a HIPAA law (which is less than 10 years old). People just weren't paying as much attention to the issue back then. Now that we have the added dangers of mass distribution of records that digitalization brings, we have gotten more conscious of the security issues.

It's a human thing ... a difference in the way people look at the records (paper vs. computer). It's not a legal thing. Legally, they are the same.

[DolceVita, ADN, BSN, RN]

Sounds a little hysterical to me. The idea being is that their electronic footprint will show they accessed a chart of someone not in their direct care (probably). Although why you, as a student nurse do not have access to the computerized charting is awfully strange to me.

For several years I volunteered for an organization that had to keep medical information on their volunteers. They would leave papers with medical information lying around in piles awaiting filing but have hysterics if anyone managed to see something on the computers. The info on the paper records was extremely complete (medical history current medications etc.) yet that on the computer was negligible -- essentially they were eligible to deploy to a disaster area or they had restrictions. These people did not understand that they needed to protect both records. Plus the person advising them was a nurse who seemingly was ill informed as well. End result they still left the papers lying around until they were filed.

If you really want to be disturbed ask the administrators in your program who has access to your health forms (that you probably competed for NS). Mine cannot tell me other than to say "they are only accessed on a need to know basis". Of course I wanted to know who decided that.

A persons record computer or paper is confidential.

[dudette10, MSN, RN]

Sounds a little hysterical to me. The idea being is that their electronic footprint will show they accessed a chart of someone not in their direct care (probably). Although why you, as a student nurse do not have access to the computerized charting is awfully strange to me.

We do not have logins for the healthcare system in which most of our clinicals are held. We do very, very little charting (mostly printed nursing flowsheets).

It's a human thing ... a difference in the way people look at the records (paper vs. computer). It's not a legal thing. Legally, they are the same.

That's what I thought, too.

[carolinapooh, BSN, RN]

The answer is that there is no real difference in looking at computer charts vs. paper charts. The act is equally right or wrong regardless of the format. However, the switch to electronic charting has heightened the sense of security/insecurity of those records and brought the question of the appropriateness of such sharing of patient information unnecessarily.

So ... if it's wrong with the computer chart, it was wrong with the paper chart, too. If it's OK with one, it is OK with the other. It's just that the paper charts were more difficult to access physically and the common practices associated with the use of the paper chart were established before there was a HIPAA law (which is less than 10 years old). People just weren't paying as much attention to the issue back then. Now that we have the added dangers of mass distribution of records that digitalization brings, we have gotten more conscious of the security issues.

It's a human thing ... a difference in the way people look at the records (paper vs. computer). It's not a legal thing. Legally, they are the same.

The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996. It's been around quite a while.

[llg, PhD, RN]

The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996. It's been around quite a while.

You are technically correct ... but a lot of the provisions in that law (and subsequent regularations) did not take effect until later. I've been in my current job since 2002 ... and it's been since then that all of our contracts with nursing schools had to be amended to incorporate much of the HIPAA language. So, a lot of those provisions have not been actually in effect for all that long -- even though the foundtion law was passed earlier.

Regardless of the exact dates for varying portions of the law ... My point was and remains that HIPAA is relatively new in the healthcare system. In the course of world history, even 1996 was not that long ago. A lot of experienced nurses, hospital policies, and common practices have been around longer than HIPAA. The laws change regularly, but old habits die hard. Even though people may know the laws, they may not make the connection between some common traditional practices (such as showing a paper chart to a student) and violations of the law. That's one reason why people don't think of showing a paper chart to a student in the same way as they do logging on to a computer and doing the same thing in cyberspace.

Thanks for sharing the date the law passed with the readers.

[HouTx, BSN, MSN, EdD]

Very interesting thread.

The transition to EHRs is creating a ripple effect that - like any other major change - may have unintended consequences. I think that this is certainly one of them.

News stories about healthcare professionals being terminated for accessing EHR information is becoming more frequent. Being found guilty of this FEDERAL violation will essentially put an end to your career since you will be put on the 'do not hire' list for any entity who receives Federal funding (medicare/medicaid, etc). So it is a very scary thing. Access to records is (by law) limited to persons involved in the patient's care. Looking at records for any other reason is a violation of Federal law. Every time a record is accessed, there is an electronic footprint showing exactly who did it - much different than casually flipping through a paper chart left on the table.

The exceptions to this rule are situations that concern public health, research, criminal investigation & education. The legitimacy of the exception rests upon the authority/credentials of the individual who is accessing (authorized medical records, researcher, educator, etc) and the documented evidence that supports the exception. Sooooooo - it is probably OK for 'educators' to utilize records for teaching purposes but the PHI (patient identifiers) may need to be protected if the information is shared with anyone who is not directly involved in the patient's care.

Bottom line to be on the safe side (at least for now), the clinical instructors should probably be the only people who are extracting EHR information - with PHI removed - for case studies to share with their students. This changes the way that clinical rotations are managed. It may seem kind of goofy, but it's the only sure way to demonstrate that a hospital is complying with HIPAA. Staff nurses are not educators and should not be put in situations where like this.

Schools should ensure that their students abide by the rules - not ask to see EHR information, not share clinical information on social network sites, etc.

[That Guy, BSN, RN, EMT-B]

We are basically told if it is not your patient, you have no business looking at the chart. Go HIPPA