Patients Viewing Nursing Notes In Real Time

[Tnurse24]

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?

[MunoRN, RN]

On 3/4/2021 at 12:46 AM, TheMoonisMyLantern said:

A radiologist's interpretation doesn't provide context and ultimately the attending physician has to determine clinical relevance. I think results should be released with the ordering provider's comments providing context for what the radiologist saw.

You are right, there are a disturbing amount of findings where follow up is recommended, and it flat out doesn't happen.

I agree the patient's primary physician, PCP, etc should have the ability to add their take on a radiologist's imaging interpretation, so long as they aren't replacing their interpretation with that of the radiologists, part of the reason for ensuring that patient's have full access to their own medical records is that too often primary physicians act as gatekeepers to this information and suppress everything but their own views and interpretations.

[MunoRN, RN]

On 3/8/2021 at 1:26 PM, 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. 

 

 

Would you rather have to deal with that accusation at the time it occurs or many months down the road?  I've never noted that the patient's behavior is inappropriate where I didn't point that out to the patient or where that observation was secret, I'm not sure what the issue would be there.  And patient's have always had legal access to the full names of those caring for them, in addition to their medical records.

[Chickenlady]

On 3/3/2021 at 9:41 PM, Susie2310 said:

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.

They can get my last name if they request the medical records, which takes time.  What I'm concerned with is my immediate safety while the psych patient in crisis is standing in front of me.  By the time they get my last name from the medical records the crisis will likely have been addressed and I'm no longer easily accessible to them. 

And as for the idealistic statement: "Nursing care is centered on the patient and their family, not the nurse.", that is the kind of idea that has gotten us to the point where there are few consequences for patients who physically attack nurses.  The safety of the provider vs. the focus on the patient are not mutually exclusive ideas although they seem to have become so in reality.  Patient centered care does not include my injury or death. 

And my hospital did just institute this policy, although we have a mechanism in the ER to not release a note to the electronic chart the patient can view online.  Still, I'm uncomfortable enough with this situation that I have not worked any ER shifts, and have no plans to do so.

[Susie2310]

On 3/8/2021 at 2:38 PM, LibraSunCNM said:

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."

 

The above sounds very reasonable and sensible to me.  The section "How might this be applied to practice?" focuses on good communication with patients and on building trust with patients, which I think we would agree is essential to good patient relationships.

[Jennifer,RN]

16 hours ago, MunoRN said:

Would you rather have to deal with that accusation at the time it occurs or many months down the road?  I've never noted that the patient's behavior is inappropriate where I didn't point that out to the patient or where that observation was secret, I'm not sure what the issue would be there.  And patient's have always had legal access to the full names of those caring for them, in addition to their medical records.

Dealing with it at the time it occurs may not be the safest depending on a patient's temperament. I don't know about you, but I've worked on a Med-Surg unit in one of the roughest neighborhoods in my state. We had A LOT of patients with unpredictable and violent behavior who would become erratic just because you didn't bring them a juice in a timely manner. Or they'd become erratic because they couldn't get a narcotic they were looking for. Sure, we point out to them that their behavior is inappropriate. However, some of these people are so drunk or high on substances that they're not going to remember that they were being inappropriate or that we told them they were inappropriate. If they don't remember and then see it in a note and become upset, then what? I personally document behavior in my notes, so that there's a trail in case anything goes down. I have been both verbally and physically assaulted and I have witnessed this with coworkers, as well. 

[LibraSunCNM, BSN, MSN, CNM]

8 hours ago, Susie2310 said:

The above sounds very reasonable and sensible to me.  The section "How might this be applied to practice?" focuses on good communication with patients and on building trust with patients, which I think we would agree is essential to good patient relationships.

Agreed!

[MunoRN, RN]

23 hours ago, Chickenlady said:

They can get my last name if they request the medical records, which takes time.  What I'm concerned with is my immediate safety while the psych patient in crisis is standing in front of me.  By the time they get my last name from the medical records the crisis will likely have been addressed and I'm no longer easily accessible to them. 

And as for the idealistic statement: "Nursing care is centered on the patient and their family, not the nurse.", that is the kind of idea that has gotten us to the point where there are few consequences for patients who physically attack nurses.  The safety of the provider vs. the focus on the patient are not mutually exclusive ideas although they seem to have become so in reality.  Patient centered care does not include my injury or death. 

And my hospital did just institute this policy, although we have a mechanism in the ER to not release a note to the electronic chart the patient can view online.  Still, I'm uncomfortable enough with this situation that I have not worked any ER shifts, and have no plans to do so.

Actually they can get your name just by asking you, since outside of defined mental health scenarios that is legally required of you as condition of your license.  You hold a license issued by the public and are accountable to the public, refusing to identify yourself to avoid accountability is typically considered more than just a mild violation by Boards of Nursing.

[MunoRN, RN]

7 hours ago, Jennifer,RN said:

Dealing with it at the time it occurs may not be the safest depending on a patient's temperament. I don't know about you, but I've worked on a Med-Surg unit in one of the roughest neighborhoods in my state. We had A LOT of patients with unpredictable and violent behavior who would become erratic just because you didn't bring them a juice in a timely manner. Or they'd become erratic because they couldn't get a narcotic they were looking for. Sure, we point out to them that their behavior is inappropriate. However, some of these people are so drunk or high on substances that they're not going to remember that they were being inappropriate or that we told them they were inappropriate. If they don't remember and then see it in a note and become upset, then what? I personally document behavior in my notes, so that there's a trail in case anything goes down. I have been both verbally and physically assaulted and I have witnessed this with coworkers, as well. 

The ability to access their medical records after a hospitalization isn't new, but I'm not clear why you feel it would be better if patient's weren't made aware of their behaviors while under the influence of drugs or alcohol.

[MunoRN, RN]

I'm still not clear what the concern is about the patient reading a nursing note related to their reported pain level.  I could see how it would become an issue if a nurse charted "Patient reports 10/10 pain, laughing on the phone, watching TV, and eating bacon, gave patient IV NS but told them it was dilaudid".  

 

[2BS Nurse, BSN]

So, I was just told by my supervisor that only providers' notes (MD, PA, NP) would be visible by patients. 

[Wuzzie]

10 minutes ago, 2BS Nurse said:

So, I was just told by my supervisor that only providers' notes (MD, PA, NP) would be visible by patients. 

Is she sure about that because I'm not certain that facilities can pick and choose what is released. All of our notes are released. There's a small icon up in the corner of the documentation window that reminds us of this.

[2BS Nurse, BSN]

Hmmm, on Epic? I will look for that!