Patients reading their own charts-yay or nay?

[HappyNurse2005, RN]

Sorry, had to remove original post.

I think someone knew who I was talking about, and thats not kosher, since I was trying to be vague enough not to violate any privacy rules

[skipaway]

I would want to read my own chart, but I would have second thoughts if my nurse had to interupt her care of other patients just to sit and watch me read it.

[Multicollinearity, BSN, RN]

I believe it is patient's fundamental right to read his/her chart. That includes allowing a representative to read the chart.

[beautifulb]

Places where I have worked had different protocols about those situations. I believe that where I am now, a physician needs to be present when the pt or any other relatives, usually the POA, looks at the charts/record in case there are any ?'s. Again, as long as it is okay with the pt.

Now, according to the first post, that is crazy to have the primary nurse to sit and watch the family pour through that chart. That could have taken over an hour.

So, the hospital's privacy officer says that that's okay, but what about your nurse MGR.? I also don't think that your ns mgr would like you off the floor that long (or to be away from your other pts.) to sit and watch them go through a chart.

[McGyverRN]

My hospital allows pt or person of pt's choice to review the chart in a supervised setting "to maintain the integrity of the chart." If the nurse does not have time to do it, then medical records will come and supervise the chart review. We are not permitted to answer questions about the content of the chart. We must refer all questions to the doc.

[brsharky]

I don't know what your facility policy is but at mine there is a formal process that a patient or POA has to go through to get a copy of their chart. The medical records staff has them sign paperwork for it and makes them a copy. We never let them look at the floor chart. They are entitled to the information but have to go about it appropriately. They cannot just demand to see the floor chart. Additionally, legally they may not be entitled to all of the information in the chart, such as certain psych notes, etc. I think that there may also be a procedure to request that certain information be withheld, psych related, if it is felt that the patient would potentially harm self or others based upon the information. As a Nurse Manager, I would not want any of the staff nurses being responsible for supervising or explaining the chart contents to a patient/family. As it was said earlier, they have more important things to do like ensure patient safety.

[Multicollinearity, BSN, RN]

I think someone from medical records (or a clerk) should supervise the reading of the chart. The nurse should not be taken away from his/her duties.

[Amy2005]

shouldn't need the nurse to be present while they read the chart, but perhaps someone from medical records

[VivaLasViejas, ASN, RN]

I've got to admit, when I was in the hospital I read my own chart. I got caught doing it, too---I was standing outside my room in my gown and robe with my nose in the progress notes when my NM came down the hall and shook her finger at me---but I figured it was my own information, and by gosh I was going to see what my labs and test results looked like and what the MD's impression was.

Now I realize what that might have looked like to another patient, who would have had no idea that I was a nurse at that hospital. Still, I don't know that I'd be able to resist the temptation again........:uhoh21:

[Multicollinearity, BSN, RN]

I've got to admit, when I was in the hospital I read my own chart. I got caught doing it, too---I was standing outside my room in my gown and robe with my nose in the progress notes when my NM came down the hall and shook her finger at me---but I figured it was my own information, and by gosh I was going to see what my labs and test results looked like and what the MD's impression was.

Now I realize what that might have looked like to another patient, who would have had no idea that I was a nurse at that hospital. Still, I don't know that I'd be able to resist the temptation again........:uhoh21:

I would do the same thing! :chair: And I'd do it again too!

[mellomom]

I've read my own chart too... while in the room, waiting for the ARNP who was called out for an emergency. While she was "suprised" I didn't feel she was angry. I discovered she had a horrible transcriptionist!

Once I read my son's chart and found a significant transcription error related to a steroid dosage...they would have been toast if he had had an adverse outcome because it looked like he'd been prescribed a 10-fold increase over normal....

I think since it's your info, you should be able to see it. I take the patient's chart in their room with me if they request it so they can see labs, etc. It really defuses upset/concerned POA/s and patients...

[TazziRN, RN]

No, unless the PHYSICIAN is there while they read it. If the pt or relative is an RN or MD or anything in between, I would have no problem allowing it, but for the general public, I think the MD should be present to interpret.