LVN keeps personal notes about patients

[VegGal]

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.

[sweetmissdixie]

We had a nurse on the floor doing this and she was told by management that it was a HIPAA violation. Subsequently, we were told in a staff meeting not to do this and not to keep our "brains" (paper sheets used for notes during each shift). If you really want to do it, maybe talk with your manager and see what the policy is. In order not to violate HIPAA, you can't keep dates or room numbers or ANYTHING that could be identifiable. Our managers told us that our charting should be detailed enough to cover us legally, so that keeping those notes wouldn't be necessary.

[Rose_Queen, BSN, MSN, RN]

Our managers told us that our charting should be detailed enough to cover us legally, so that keeping those notes wouldn't be necessary.

This. What is it that is being journaled that isn't covered in the charting, and why isn't it covered in the charting if it's significant enough that the nurse is journaling about it?

[Davey Do]

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.

There's a sense of deep caring and commitment here, in that someone would go out of their way to keep a journal about these things when they really don't have to.

To allow the fear of something that might happen to curtail such an endeavor would be a crime; it would be not experiencing life to the fullest.

I know not what course others may take, but as for me, to hell with HIPPA and full steam ahead!

Okay. That was a little dramatic. But you get the gist.

[DeeAngel]

Keep your nose out of it and know nothing about it.

[Conqueror+, BSN, RN]

Been doing it for 20+ years and it can save you. You will NOT remember a patient years later but the documentation is there.

[Buyer beware, BSN]

I must say I do like Davy's reference to journaling as a therapeutic device and as long as there is no patient specific identifiers believe there is no harm done nor laws broken.

Now the legal aspects of this, who knows? But I believe this question could act as part of the impetus for schools of nursing to teach law as it specifically affects nursing practice instead of Nursing Theory I-VI and having to look up legal precedents on Nexus Lexus if so inclined.

[kbrn2002, ADN, RN]

I use a "cheat sheet" that does have all my residents names on it. I use it to jot down notes and reminders to myself such as things to pass along in report that don't necessarily need to be documented in the charting. I also jot down things that already are documented that the oncoming nurse should be updated on during report for her to follow up on. I shred this at the end of my shift but I do know a few nurses that keep the sheets. This is OK as long as it never leaves the building.

It might be OK to take the notebook home as long as there is absolutely no identifying information in it, but I don't imagine any notebook/brain sheet would be very useful to the writer if there is not enough identifying information to remind yourself later exactly why you noted what you did. Smartest move if you intend to keep any brain sheets is to make sure you never leave the building with them.

[RNrhythm, BSN, RN]

In my LTAC people usually keep their brain sheets until their days off. Because they contain HIPAA info, no one takes them home but leaves them in a designated cabinet in the unit.

[RNrhythm, BSN, RN]

Been doing it for 20+ years and it can save you. You will NOT remember a patient years later but the documentation is there.

I am new in my RN career and your post fascinates me. I recently had someone ask me about an intake assessment I did nearly a year ago and I did not recognize the name at all, even after looking at my charting. All I could say was that if that is what I carted, then that must have been what I observed.

How do you do your own journaling? Do you do it as you work? After shift? Do you carry a notebook?

[Beldar_the_Cenobite, CNA]

If you have like an Ipad or a small notebook and jot down the room number and the intials of the patient I don't see why its a problem. As long as it doesn't look like it could be used against the patient. Like if you have John Smith rm 1168, you could do Px11J68S (px is patient) and if he has Alzheimers (Px11J68S-Az d.). Mix the numbers, just don't leave anything that could give away your patients. Something that you know only and can remember and that something no one will be able to understand. If you have to use character map from your computer, then by all means create your own alphabet. I think keeping health care providers from knowing their patients is a bit ridiculous because that makes the job harder and I think breeds potential problems.

Somethings in life should be simplistic, a lawyers nose OUT OF THE WAY....

[nurse2033, MSN, RN]

Any records you keep to "cover" yourself can be subpoenaed and entered into the court record. I don't think you are gaining any coverage. It could just as easily be used against you.

[Nurse SMS, MSN, RN]

Does it leave the building with her or does it stay at work, hopefully locked in a locker? I think the answer to that question would largely determine whether it is a potential HIPAA violation.