Patients Viewing Nursing Notes In Real Time

[Tnurse24, RN]

Is anyone aware of a new CMS rule that all nursing progress notes are to be made available to patients in real time? This is the default at my hospital, and it is a HUGE safety risk to ER staff who are already vulnerable to erratic and unpredictable behavior as well as wide open to the public. Is anyone else aware of these requirements? What is being done to protect individuals from potential violence or security issues?

[Chickenlady]

Huge safety risk.  If my hospital does that, there will be one of three outcomes:

1.  Incomplete notes

2.  Staff will be in danger

3.  Staff will quit

OK.....maybe all three of those things will happen, but I will be in group #3. 

[BabySweetpea]

This is a new law and I believe it goes into effect April 1st. I’m very nervous as I see so many risks.  

[MunoRN, RN]

Patients have had legal access to their medical records, including nursing notes, since long before the current law which just limits how much of a hassle it can be to access your medical records.  The law has actually been a law since 2016, the deadline for compliance is coming up.  The law includes reasonable exceptions in the case of psychiatric notes, for instance.

We've been using a portal with immediate, real-time access to notes, I have no problem with it.  There's nothing in my notes that I wouldn't straight up tell a patient, so being able to read the notes isn't really an issue.

What are the things people worry patients will know about that they wouldn't have otherwise known?

[Emergent, RN]

This instant gratification society is getting very old. Can't wait to retire. 

[Kitiger, RN]

A friend of mine told me of the time his mother was in the hospital (around 35 years ago). He read his mother's chart, and he became very angry to see that the nurse had described his mother as SOB!

If patients may read their charts, we might have to be careful of what acronyms and abbreviations we use. ?

[Wuzzie]

2 hours ago, MunoRN said:

What are the things people worry patients will know about that they wouldn't have otherwise known?

It is an issue on telephone triage. For example, we had a family member call in about their loved one who was not caring properly for themselves and had expressed hopelessness with some disturbing dialogue.  While we couldn’t discuss the patient with the family member we had to document what the call was about. Since it wasn’t psychiatric notes (oncology triage) it went straight to the patient before we could intervene. It caused huge trust issues within that family unit and also between the patient and his onc team. It resulted in a disruption of care and now there isn’t anyone helping the patient because he is no longer speaking to his family. 

Since we implemented this practice a couple of weeks ago we are now being inundated with frantic phone calls regarding imaging results that are being released before the provider has a chance to review them. Because the parameters for suppressing patient information are stringent people are finding out their cancer has progressed via computer. 
 

While I agree that patients have a right to see their records and the hoops they had to jump through to do that were absolutely ridiculous I do not think this is the way to remedy it. It’s another one of those things that looked good on paper but did not have the desired results when put into action. The pendulum has swung too far the other way. 
 

FTR, I too will stand by whatever I document...every cuss word, every threat and every name I get called. ?

[Tnurse24, RN]

2 hours ago, MunoRN said:

Patients have had legal access to their medical records, including nursing notes, since long before the current law which just limits how much of a hassle it can be to access your medical records.  The law has actually been a law since 2016, the deadline for compliance is coming up.  The law includes reasonable exceptions in the case of psychiatric notes, for instance.

We've been using a portal with immediate, real-time access to notes, I have no problem with it.  There's nothing in my notes that I wouldn't straight up tell a patient, so being able to read the notes isn't really an issue.

What are the things people worry patients will know about that they wouldn't have otherwise known?

For ex. a pt in a manic episode presented w. her children who were afraid of her and refused to return home. This prompted a report to cps and a police report. The children were removed from her care pending further investigation. This person knows my name, where I work, my shift and has unpredictable behavior- and every word I wrote supported the psych eval, cps, and sw consult that resulted in her losing her children. The law covers psychiatric consults, not nurse notes. The security at my hospital is non-existent. This presents all three of the issues cited by @Chickenlady

[MunoRN, RN]

16 minutes ago, Tnurse24 said:

For ex. a pt in a manic episode presented w. her children who were afraid of her and refused to return home. This prompted a report to cps and a police report. The children were removed from her care pending further investigation. This person knows my name, where I work, my shift and has unpredictable behavior- and every word I wrote supported the psych eval, cps, and sw consult that resulted in her losing her children. The law covers psychiatric consults, not nurse notes. The security at my hospital is non-existent. This presents all three of the issues cited by @Chickenlady

The CURES act specifically excludes notes that may be used to support an abuse claim, although such notes are still subject to being called into evidence in court, just as they have always been.  

[MunoRN, RN]

1 hour ago, Wuzzie said:

It is an issue on telephone triage. For example, we had a family member call in about their loved one who was not caring properly for themselves and had expressed hopelessness with some disturbing dialogue.  While we couldn’t discuss the patient with the family member we had to document what the call was about. Since it wasn’t psychiatric notes (oncology triage) it went straight to the patient before we could intervene. It caused huge trust issues within that family unit and also between the patient and his onc team. It resulted in a disruption of care and now there isn’t anyone helping the patient because he is no longer speaking to his family. 

Since we implemented this practice a couple of weeks ago we are now being inundated with frantic phone calls regarding imaging results that are being released before the provider has a chance to review them. Because the parameters for suppressing patient information are stringent people are finding out their cancer has progressed via computer. 
 

While I agree that patients have a right to see their records and the hoops they had to jump through to do that were absolutely ridiculous I do not think this is the way to remedy it. It’s another one of those things that looked good on paper but did not have the desired results when put into action. The pendulum has swung too far the other way. 
 

FTR, I too will stand by whatever I document...every cuss word, every threat and every name I get called. ?

And if I'm that patient then I expect to have access to all of the information that is used to determine my course of care, regardless of whom may prefer that I be kept in the dark.  If I found out my family has been trying to put me in a home against my will, and then I'm done with them, then there is no reason to see that as a bad thing.  And as the nurse I have never had any problem sharing that information with the patient regardless of what law says I have to share it.

As to imaging results, all results released to a patient are already interpreted by a provider (a radiologist), there is no reason to supress this information from patients, particularly since one of the major drivers of making imaging results more accessible to patients is the disturbing number of patients who had incidental findings on imaging that recommended interval follow up which never occurred because it was up to the provider to inform them of that.

[Susie2310]

1 hour ago, Wuzzie said:

It is an issue on telephone triage. For example, we had a family member call in about their loved one who was not caring properly for themselves and had expressed hopelessness with some disturbing dialogue.  While we couldn’t discuss the patient with the family member we had to document what the call was about. Since it wasn’t psychiatric notes (oncology triage) it went straight to the patient before we could intervene. It caused huge trust issues within that family unit and also between the patient and his onc team. It resulted in a disruption of care and now there isn’t anyone helping the patient because he is no longer speaking to his family. 

?

I don't know your facility's internal process for handling such a call from a family member, but I assumed the patient had not given your facility a documented instruction that their family member could receive the patient's HIPAA information.  It seems possible that looking at what went wrong and changing the internal process would avoid situations such as this.  The unfortunate situation you described doesn't mean that there is anything wrong with making patient's medical records/nursing notes available to patients in real time or that this not beneficial to the patients.

[Susie2310]

On 3/3/2021 at 5:29 PM, Chickenlady said:

Huge safety risk.  If my hospital does that, there will be one of three outcomes:

1.  Incomplete notes

2.  Staff will be in danger

3.  Staff will quit

OK.....maybe all three of those things will happen, but I will be in group #3. 

As things are now, patients have the right to know the first and last name of the nurse caring for them, and they or their authorized family member/s or their legal representatives can obtain their medical records which have the names of the staff who provided their care.

Nursing care is centered on the patient and their family, not the nurse.