Med errors: subpoena, copy of incident report

[nursing.mypassion]

Why can't a nurse make a copy of the incident report (of the medication error the nurse made) as a personal file? Yet, she can keep a writing note of the incident. The NCLEX-RN rationale is that the nurse can be subpoenaed in court ? (it's a NCLEX-RN question and rationale that I don't understand). I don't understand? Help would be greatly appreciated

[Esme12, ASN, BSN, RN]

qoute[Why can't a nurse make a copy of the incident report (of the medication error the nurse made) as a personal file? Yet, she can keep a writing note of the incident. The NCLEX-RN rationale is that the nurse can be subpoenaed in court ? (it's a NCLEX-RN question and rationale that I don't understand). I don't understand? Help would be greatly appreciated] end qoute

Technically the incident report doesn't exist.....but to copy the document for your own purpose or records is in violation of HIPAA laws which states using the patient record for purposes other than the care of that patient without their permission ois unlawful and punishable. Especially when you remove the information form the hospital (which we all know we can't do...right:rolleyes:) I'd have to see the whole NCLEX question to give the best answer but technically anyone who's touched the chart can be subpoenaed by the court.

http://www.whavins.com/nplh21.htm

http://www.enotes.com/everyday-law-encyclopedia/medical-records

You can, however, request the hospital ot allow you to see the record you have been subponeaed for before court or deposition and I would request to speak with the hospital lawyer for advice as well as call my malpractice insurance for advice. Interesting sites listed above going over medical record laws and subponeas for reading in your spare time.... They are very informational.

Now, that being said, I have "jotted" down noted and key points of certain stand out incidences that had a high potential for litigation or if something was just "not right"....that gut feeling you get when somethings not right. But be very careful.....if the information got dropped outside or left in a store and there are identifiers for the patient that is a big deal!!!!! Breech of confidentiality, invasion of privacy, breech of contract (remember that confidentiality agreement you sigened?), possesion of stolen goods (hospital records) violation of HIPAA....all big deals!

To the new grad filling out all those incidnt reports.....I am sure she is required by the nursing home to file these reports. In leiu of all thre lawsuits for neglect and abuse basesd on skin breakdown ans reinbursement being effected........the only way to 'keeptrack" is through reporting a mechanism which may not be perfect but it is all they have.

Good Luck on NCLEX!