Does anyone have a policy or process on reasons for not sharing notes with a patient or family on the EMR. In our system, there is a way to block notes from being automatically shared to the patient's record. For example, let's say you have an unpleasant patient or family member that is disruptive and it's getting to the point of effecting the care of the other patients and you are questioning getting security involved. You may make an event report of some kind to describe what is going on, but you also want to have notes in the chart backing up what you are saying, as you don't ever put a note in saying that you are submitting an event report. I may not want to share the note with the patient or family in fear or making them either angrier, or for fear of retaliation or just making the working relationship worse. Maybe if they read a note from the RN describing the things happening, it would just set them off. Whoever is reading the event reports reviews the patient chart, and there are no notes in the chart describing any of the things I am claiming are taking place. I want to put objective notes in the chart, as my peers do as well, but we don't want to make the patient/family behavior worse. If family were to complain about staff, we would like there to be some reference to what has been going on besides a single event report that is not corroborated when reading the patients chart. So, if we put notes in describing these types of things, would it be appropriate to NOT share those notes with the patient?
Glad you are fine. So nice of you to dismiss others that have concerns. We had a nurse get shot in the ED. You win, you're tougher than the rest of us. Glad healthcare violence on health care workers is "drama"
You may make an event report of some kind to describe what is going on, but you also want to have notes in the chart backing up what you are saying, as you don't ever put a note in saying that you are submitting an event report. I may not want to share the note with the patient or family in fear or making them either angrier, or for fear of retaliation or just making the working relationship worse. Maybe if they read a note from the RN describing the things happening, it would just set them off. Whoever is reading the event reports reviews the patient chart, and there are no notes in the chart describing any of the things I am claiming are taking place. I want to put objective notes in the chart, as my peers do as well, but we don't want to make the patient/family behavior worse. If family were to complain about staff, we would like there to be some reference to what has been going on besides a single event report that is not corroborated when reading the patients chart. So, if we put notes in describing these types of things, would it be appropriate to NOT share those notes with the patient?
My first place of employment (eons ago--mid 90's--- ?) had a legal nurse do an in service about writing proper nursing notes. Back then, there was no Cures Act that allowed patients to see notes, but the lesson we learned was, if we were writing notes that we thought the patient or family would be upset to read, then we were writing them wrong. The emphasis was on writing neutral, objective notes.
It's been so long to give specifics, but I do remember that one of my notes was chosen because I wrote "patient was upset because his pain medication had not been given..." ?and the objective correction was, "patient expressed concern about the pain medication wait time." Something along those lines...We learned so many things never ever taught in nursing school, unfortunately.
So maybe in addition to hiding notes, maybe also learning about writing notes from a legal perspective could help in writing notes that you don't want family members to see. I know that when I did travel nursing and I told other nurses about writing "legalese" notes, most if not all, were amazed that they had never heard of that concept. Then again, this in the mid-late 90s, so no clue how things have changed. Maybe now nursing schools offer a class on writing objective nursing notes from a legal perspective.
Glad you are fine. So nice of you to dismiss others that have concerns. We had a nurse get shot in the ED. You win, you're tougher than the rest of us. Glad healthcare violence on health care workers is "drama"
When I read this, I missed the part about a nurse being shot in your ED. That is, indeed, a tragic and traumatic event. It can take. long time, if ever, to move on from this. I'd need some therapy after that for sure!
Thanks for sharing. I was unaware it was possible to hide these notes. I was aware of EPICs "sticky note" feature which is only on the users page, which I think can also be shared to members of the healthcare team?
Luke79AU
35 Posts
Far out. Time to move?