Patients Viewing Nursing Notes In Real Time

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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?

5 minutes ago, 2BS Nurse said:

Am I incorrect in thinking it's only the provider's progress notes available to patients (excluding test results, etc.)? If not, why are we not getting any specific training around this change?

No, it’s everything except a very few specific examples (HIV results, psych notes). Our triage call notes get sent which is now annoying the patients because some of them take multiple calls to resolve and they get an individual email notification for every single note made in a single call as well as such things as if we fax a progress note at the request of other MD offices. We have begun to get complaints about it. The irony is we have to document the complaints about the notifications which causes them to get a notification about the documentation about the complaint about the notification. ??

Like I said. This was not well-thought out. 

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Just now, Wuzzie said:

No, it’s everything except a very few specific examples (HIV results, psych notes). Our triage call notes get sent which is now annoying the patients because some of them take multiple calls to resolve and they get an individual email notification for every single note made in a single call as well as such things as if we fax a progress note at the request of other MD offices. We have begun to get complaints about it. The irony is we have to document the complaints about the notifications which causes them to get a notification about the documentation about the complaint about the notification. ??

Like I said. This was not well-thought out. 

Seriously????? 

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1 minute ago, 2BS Nurse said:

Seriously????? 

Yep. Brilliant isn’t it?

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Just now, Wuzzie said:

Yep. 

Ugh! We are going live on this soon. Looks like my notes are getting waaaaay less detailed. ?

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Just now, 2BS Nurse said:

Ugh! We are going live on this soon. Looks like my notes are getting waaaaay less detailed. ?

I haven’t changed my documentation at all. I do my best to chart objectively, try to use minimally incendiary verbiage ( declined vs refused), use lots of quotation marks and worry very little if a patient gets cheesed off at me for documenting their bad behavior. But again, I’m old, have developed a thick skin and wouldn’t think twice about hanging up on a patient (or “terminating the call”-less incendiary)who calls me names after giving them a warning. The thing is, if a patient is being verbally aggressive (less incendiary term than “abusive”) and I document it and they call the patient complaint line and start screaming at them it kind of proves my point. Also, those calls are recorded so let them scream. ?

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Specializes in ER.

Sorry to disagree, but there is no way on God's green earth that anyone can be smiling and chowing down while in 10/10 pain.

Maybe it means they can't count, or more likely,  they are prone to gross exaggeration. 

 

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I'm not against patient's having access to their medical records. What I am against is that sometimes we write progress notes that describe a patient's behavior if it's inappropriate. What if that patient then tries to come after the nurse stating that that never took place? They have the nurses full name. I'm not comfortable with that. 

 

 

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Specializes in OB.

I get sent clinical scenarios by email monthly from an online CME program from a prior job that seems to have forgotten to take me off their listserv.  The most recent one was about the CURES Act, and offered some nice guidance, IMO.  I wish I could provide the link to the whole online course, but here is the conclusion copied and pasted:

"What can be learned from the experiences portrayed?

The Cures Act gives patients unprecedented access to and control over their medical records.5 Under the Cures Act, the majority of patient medical documents, laboratory results, radiographic imaging reports, and pathology results are released to patients once finalized.

Patients may have access to laboratory testing, procedure results, and radiographic imaging results—including incidental findings—before their provider reviews of the results; this may cause stress or anxiety

Patients may interpret or misunderstand medical jargon or diagnoses, leading to unnecessary conflict and mistrust3

Be mindful of the language you use in the medical record; be especially mindful when it comes to documenting behavioral health concerns because patients with these concerns may be particularly sensitive to what is written about them

This stress, anxiety, or conflict may negatively affect the patient-provider relationship if preparations are not made in advance

Patients can benefit by having direct access to their medical record, including:

Improved understanding of their health and diagnoses

Better recall and compliance with their care plan

Increased feelings of control over their health

Improved self-care

Improved medication adherence

How might this be applied to practice?

Manage patient expectations—Be sure to discuss with patients why you are ordering tests and what the results may show. Let patients know that they may receive the results before you have a chance to review them. Assure patients that you will call to follow up on any abnormalities once you have reviewed the results.

Access to information does not equal understanding information—Discuss the use of medical jargon with patients, being mindful of any implicit bias. “Obese” carries a different meaning for medical professionals than it does to non-medical persons. Consider using alternative terms in your documentation to reflect neutral connotations (eg, BMI 32 instead of obese).

Ensure that medical record access does not change your relationship with your patients—Patient-provider trust and communication are cornerstones to preventing dissatisfaction and litigious outcomes.6 Furthermore, shared decision-making is part of the consent process and improves patient satisfaction.3,6 The single most important factor when it comes to avoiding litigation is trust. “Our research shows that easy access to notes builds trust, even when errors are noted and corrected.”3 Be mindful of the language that you use to describe your patients and their concerns in their medical records, knowing that your patients may very well be reading what you write.

This transition will take time, and communication between both parties is vital. Reiteration and support will be key factors in navigating the changes. Many of the recommendations and provisions are still being finalized. Therefore, it will be necessary for providers to ensure that they are current on the most recent directions to reduce risk and improve care."

I honestly don't think the CURES Act will change patient care all that much, in that I simply don't believe many patients will take advantage of the new changes.  But I found the above guidance to be sensible and applicable to many aspects of our jobs.

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4 hours ago, Jennifer,RN said:

I'm not against patient's having access to their medical records. What I am against is that sometimes we write progress notes that describe a patient's behavior if it's inappropriate. What if that patient then tries to come after the nurse stating that that never took place? They have the nurses full name. I'm not comfortable with that. 

 

 

Exactly!! We have too many patients out there with psych issues! What I really don't understand is... why haven't we gotten any training around this CURES act??

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On 3/3/2021 at 7:26 PM, BabySweetpea said:

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

I’ve been away from hospitals for a couple years now. This shocks me. If a patient wanted to view their chart they could but it would be with a nurse present. If they wanted to go through everything they could sign a release at discharge and get it. Real time is crazy. Sometimes charting didn’t get finalized until shift change. I had my notepad but actual legal charting sometimes had to wait if I had patients crashing.

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This is starting to sound worse than the whole patient satisfaction scores for hospital reimbursement. We saved your life. We gave you narcan. We wouldn’t give you IV push dilaudid after you OD’d. You now hate us. Doc charted that you were drug seeking. Now you REALLY hate us....yeah, this will be a *** show. Glad I’m not there to participate.

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22 hours ago, Emergent said:

Sorry to disagree, but there is no way on God's green earth that anyone can be smiling and chowing down while in 10/10 pain.

Maybe it means they can't count, or more likely,  they are prone to gross exaggeration. 

 

I completely agree with you.  In my previous post, I noted the politely-phrased way I'd explain my use of objective pain descriptors to a patient who asked. 

  • I would have no problem explaining to a patient why I wrote "visiting with family member, smiling, eating pancakes and bacon" when they reported 10/10 abdominal pain. "Every patient experiences pain differently. Some patients are smiling and pleasant when they report 10/10 pain, and others are pale, sweaty, and doubled over holding their stomachs when they report 10/10 pain. Using descriptive terms in addition to the numeric pain scale helps team members understand how you experience pain so we can individualize your care and serve you better."  

Patient's Takeaway: The nurse's explanation for why she writes these descriptors makes sense.  The healthcare team needs to understand my pain experience.

My Clinical Takeaway:  These descriptive terms shows that you clearly do not grasp the 0-10 pain scale concept.  Factually, someone experiencing true 10/10 abdominal pain won't be smiling, happily visiting, and eating a large meal.  By including these descriptors to paint a complete and accurate picture of the patient's condition, I've defended my choice to offer ibuprofen or Norco instead of the strongest IV opioid available.   

There are so many patients who simply do not grasp the concept of numeric scales.  There are also patients from certain cultures that were never taught about numeric scales in their countries.  The nurse might ask "On a scale of 0-10, where 0 is no pain, and 10 is the worst pain physically possible, how would you rate your pain?" These patients hear two options and choose accordingly: 0- no pain, 10- pain.  While I understand that pain is subjective, I think it's poor judgment to medicate based on the numeric pain score alone, I.e. PRN opioid orders for pain rated 8/10.

How we know that most patients don't understand the numeric pain scale:

How many times a day does someone tell you their pain is 20 or 100 on the 0-10 scale?

How many times a day does a patient tell you they feel "much better" after their IV opioid, but their pain rating only drops from 10 to 9?

How many times have you heard "It's a 10.  I just tolerate it really well because I'm used to it."  (By definition, 10 of 10 is intolerable.)

How many times do patients report a pain level of 10 with the comment "It's just a little sore.  It doesn't bother me that much."  After re-educating these patients on the pain scale, they say "Oh, it's not that bad.  I guess you can call it a 9 then." 

I think we should drop the numeric scale all together. 

 

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