LVN keeps personal notes about patients

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Specializes in LTC Management, Community Nursing, HHC.

An LVN at work (LTC) showed some of us a large notebook that she keeps with info on her patients on a daily basis. She makes notes about them, about things that she's done for them, or conversations with them, changes in their condition, and even has notes from change of shift report written in there. She says that the DON (RN) does the same thing and that's why she does it.

I'm a little unsure if that's a good thing or not. I think that it could be a HIPAA violation, couldn't it? Even if there are no names in there, she probably has room numbers, or bed numbers. While I understand that she thinks she's doing that to cover herself should the need arise, is that necessary? What do you guys think?

Thanks.

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Specializes in Psych (25 years), Medical (15 years).
An LVN at work (LTC) showed some of us a large notebook that she keeps with info on her patients on a daily basis. She makes notes about them, about things that she's done for them, or conversations with them, changes in their condition, and even has notes from change of shift report written in there.

You know, VegGal, that is an interesting situation and I'm relatively sure some will poo-poo your coworker's journaling, but I am a big fan of keeping records for one's own use.

A journal is a record of personal, and in this case, also professional growth. I've been journaling for over 40 years and believe the process to be extremely therapeutic. The process of writing is a great way to assimilate information.

As far as a HIPAA violation, I don't know... If there is no way to connect the patient with identifying data, I don't see then how it could be violation of anyone's rights.

I applaud your coworker's journaling, and you too, VegGal, for your endeavor to gather data and compare notes.

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Probably is not enough reason to suspect HIPPA violation

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Specializes in Nephrology, Cardiology, ER, ICU.

Moved to HIPAA forum

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Specializes in LTC Management, Community Nursing, HHC.
You know, VegGal, that is an interesting situation and I'm relatively sure some will poo-poo your coworker's journaling, but I am a big fan of keeping records for one's own use.

A journal is a record of personal, and in this case, also professional growth. I've been journaling for over 40 years and believe the process to be extremely therapeutic. The process of writing is a great way to assimilate information.

As far as a HIPAA violation, I don't know... If there is no way to connect the patient with identifying data, I don't see then how it could be violation of anyone's rights.

I applaud your coworker's journaling, and you too, VegGal, for your endeavor to gather data and compare notes.

Thank you, Davey Do. I'm all for journaling and I do so in my free time, however I'm wondering that if the reason to keep such a journal is to protect one's self in the event of an inquiry, then wouldn't there be some way to identify what was done and for whom? If it's not a HIPAA violation, I definitely see the benefit in doing it, but it worries me that if I did, I'd have to put down room / bed numbers, dates of care, and maybe that would be too much info on patients that I'm taking home with me. What do you think, Davey Do?

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Specializes in LTC Management, Community Nursing, HHC.
Probably is not enough reason to suspect HIPPA violation

Thank you, Atl-Murse. If that's really the case then I see the benefits in keeping notes / a journal such as that. I believe it could come in handy for the nurse to look things up in the future, or even to defend one's actions should that become necessary. I wish I didn't have to consider stuff like that, but considering that we chart by exception, maybe she feels the need to document other things that she doesn't chart on.

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Hey! I'm not sure it's a HIPAA violation, but I was once advised to keep my shift brain sheets to be sure I can cover myself. I don't think it's such a bad idea, but I could see your reason for concern

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Specializes in nursing education.
Hey! I'm not sure it's a HIPAA violation, but I was once advised to keep my shift brain sheets to be sure I can cover myself. I don't think it's such a bad idea, but I could see your reason for concern

I was advised to NOT keep shift sheets or notes because in the event of a lawsuit, if it was discovered that a nurse had kept these then they would all be discoverable/subpoenaed. That was before HIPAA though. Now I am wondering if that was good or bad advice.

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Specializes in Pediatrics, Pediatric Float, PICU, NICU.
I was advised to NOT keep shift sheets or notes because in the event of a lawsuit, if it was discovered that a nurse had kept these then they would all be discoverable/subpoenaed. That was before HIPAA though. Now I am wondering if that was good or bad advice.

I was informed when I started nursing 10 years ago that keeping my report sheets was a HIPAA violation.

In regards to the OP, I could see the concern for HIPAA violations. I think there is also a difference between journaling as a therapeutic measure for yourself, and keeping notes to CYA. I knew a nurse of 30 years who kept notes on his patients, every patient, just in case something every came up. I've personally never felt like I needed to keep notes consistently because I feel extremely confident in my charting. However the few times where I felt there would potentially be a "problem," I have sent a secure email via my work email to my manager so there was a paper trail.

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I was advised to NOT keep shift sheets or notes because in the event of a lawsuit, if it was discovered that a nurse had kept these then they would all be discoverable/subpoenaed. That was before HIPAA though. Now I am wondering if that was good or bad advice.

Yeah, that's true. If they know about it, then it can be subpoenaed. An risky practice. I do it on occasion (clinical days) , but on my second day I toss them. Goodness forbid we'd find ourselves in that situation, knowing the consequences of it, I would NEVER mention that I had the documents. Just hoard them in silence lol

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Encourage the LVN to ask her provider if keeping a journal of conversations with patients, changes in their medical condition and change of shift notes, is violating patient confidentiality and privacy and if the journal can be subpoenaed in court.

The journal contains confidential health information without the informed consent of the patient

The journal contains conversations and unique medical information that may make it possible for a patient or colleagues to identify a patient

The journal is not stored in a secured manner

A malpractice lawyer can clarify some of misconceptions that the LVN has about keeping a journal, it is not as harmless as she believes.

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Specializes in Acute Care, Rehab, Palliative.

Would a private diary stand up in court if you were keeping it to CYA?

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