Nursing notes


When I need to document something, I use a school nurses note that says "private and confidential for nursing use only" at the bottom. Can those be called into court?

Just wondering....



Flare, ASN, BSN

5 Articles; 4,431 Posts

Specializes in school nursing, ortho, trauma.

do you mean like your regular documentation of the office visits you see? I would say yes, those can indeed be called into court. They would need to be subpoenaed properly. I wouldn't allow just anyone claiming to be an attorney into my office to browse into my files. But regardless of the disclaimer on the bottom, if your handiwork gets called before a judge your records can and will be looked at.

On the other hand... i have had times that i've written up "off the record" type things that i haven't put into the children's personal health files. Mostly behavioral type things CYA type things that i wanted to hold onto in case I ever had to refer back to it or defend myself at a later date... but then again isn't that what documantation is all about?... covering our butts...