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?

[Wuzzie]

21 minutes ago, 2BS Nurse said:

Hmmm, on Epic? I will look for that!

Yes it's a little pink icon in the upper right hand corner. The reason I questioned you was because we were told the same thing you were until it was discovered that we were told incorrect information.

[2BS Nurse, BSN]

Very typical. I do believe you. Our written communication says "clinicians notes". I'm not sure how they are defining "clinicians". We haven't had a single phone call or complaint about too many email notifications though. 

[Daisy4RN]

On 3/11/2021 at 7:44 AM, 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.

 

On 3/10/2021 at 3:53 PM, 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.

Agree completely with these statements. I have also worked with pt populations that this would not fly. One place we had disgruntled patients follow nurses out to the parking lot and harrass them and vandalized their cars (mine included). There is no way them reading the notes would have prevented this, only exacerbated it. There is a reason why patients have not had immediate access to their records, one is to give time for them to meet with their MD for explanation of the records in lay terms as well as explain the entire picture. There is nothing wrong with pt centered care until it affects the safety of either pt or staff. 

[ladyapj, ADN, EMT-I, EMT-P]

On 3/3/2021 at 6:47 PM, 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?

I requested to see my records as a patient back in the early 90's. The nurses seemed upset by this, but I was allowed to see them. I wasn't checking up on the nurses, I was checking up on the doctors. Turned out I was right about my suspicions. Most people wouldn't know how to interpret anything they read in the record anyway.

[morte, LPN, LVN]

On 3/6/2021 at 3:17 PM, Susie2310 said:

My comments that you are taking issue with were: 

Susie2310   

 Add your Credentials, Experience, etc.

654 Likes   1,974 Posts

17 hours ago

   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.

My reply to the above poster was:

"A facility can add a note to the released record stating that the ordering provider needs to provide context for the radiology report findings.  I've seen this done."

 

Then I replied to your first reply to me:

Susie2310   

 Add your Credentials, Experience, etc.

654 Likes   1,974 Posts

59 minutes ago

   6 hours ago,  Wuzzie said: 

You can’t really think a generic note like this will make a difference? A personal note from the provider sure but an auto-response? Come on.

My reply to you was:

"I'm not talking about an auto-response.  I'm talking about a message appended to the radiology results stating that context for the radiology report needs to be provided by the ordering provider, which is followed up timely by the ordering provider interacting with the patient to provide  this context, or, if the ordering provider has already viewed the report when the patient receives it, the ordering provider can use their judgment to include a personal note along with it. " 

Then I replied to your second reply to me:

Wuzzie     

9,818 Likes   4,230 Posts

41 minutes ago

   1 hour ago,  Susie2310 said: 

I'm talking about a message appended to the radiology results stating that context for the radiology report needs to be provided by the ordering provider, 

How is that any different? You still have a patient with a report that they don’t understand and looks to them like their cancer is back or progressing. What is the value in having that report released? How can anyone think this doesn’t result in harm to the patient? What is the risk in delaying it for say 24-48 hours to give the provider time to review and make a notation?

I replied that:

"I said that if the ordering provider has already viewed the report they can use their judgment to send a personal note along with it.  I would also presume that for significant findings the radiologist would contact the ordering provider promptly, so the ordering provider would be able to contact the patient timely if necessary."

My clarifying and adding more information so you can more fully understand my position doesn't signal any negative behavior on my part. 

Wuzzie, it's fine with me if you disagree with me - I have no problem with agreeing to disagree, but I don't see any value in both of us continuing to go back and forth, so I'm not going to continue to debate this point with you any further.  

 

 

 

 

 

Because there is nothing of consequence that you can add.  You are on the wrong side of this discussion, again.

[Jennifer,RN]

On 3/11/2021 at 4:49 PM, MunoRN said:

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.

I never said I wouldn't make them aware of their behaviors. I'm saying making them aware while under the influence, they may not remember. This is where nursing notes come into play. I personally document behavior in notes. If they don't remember how they acted and then read it in a nursing note and become upset because they don't remember, then what?

[trytounderstand]

5 hours ago, Jennifer,RN said:

never said I wouldn't make them aware of their behaviors. I'm saying making them aware while under the influence, they may not remember. This is where nursing notes come into play. I personally document behavior in notes. If they don't remember how they acted and then read it in a nursing note and become upset because they don't remember, then what?

But...perhaps they do remember but all they remember is they were chastised or told they were argumentative or non-compliant...patients should have the ability to read the nurses notes and question what is being said about their behaviors.  At the time they were having bad behaviors it may have been out of anxiety, fear of what was happening, not understanding what was happening.  I have witnessed nurses who have become upset and reported bad behaviors because a patient asked why or wanted to make their own choices about their body...reporting that patient was argumentative and non-compliant just because they denied a medication or questioned the need for the medicine or even asked for second opinion....This record may follow the patient for several days in a hospital situation and they should have the ability to explain why they were upset, why the did not want to take the medicine or why they wanted a pair of tear away shorts that somehow the nurse kept forgetting to bring and other caregivers made sarcastic remarks about the patient requesting such shorts.

On the other hand yes you should report if the patient becomes threatening, calls names, is offensive in any way. No one should have to feel unease whether it be nurse, doctor, CNA or patient.  Yes that should be documented but the patient should still have the ability to repudiate and defend themselves.  Both sides of the story needs to be reported and kept on file.

At the same time if there is real time access to medical records, there should also be real time access for patients to contact a patient advocate.  Get someone in there to mediate a bad situation before it goes totally off the rails.  If a patient feels that he/she is not being heard or advocated for, there should be a way for that patient to get a assistance while the situation is happening not days later after whatever is happening has already taken place.  Perhaps bad decisions or outcomes on all sides....

 

[MunoRN, RN]

6 hours ago, Jennifer,RN said:

I never said I wouldn't make them aware of their behaviors. I'm saying making them aware while under the influence, they may not remember. This is where nursing notes come into play. I personally document behavior in notes. If they don't remember how they acted and then read it in a nursing note and become upset because they don't remember, then what?

You're worried that they will become upset if they know what the effects of their alcohol or drug abuse are in terms of their behavior while under the influence?  Making them aware of those negative consequences isn't something that should be avoided.

[NurseLy, BSN, RN]

Our names show up in the patient chart that they can access with our first name and last initial only.

There is still an option for us to keep notes hidden. In our EPIC there is a button we can click to keep the note confidential. There has to be a good solid reason to use the button, I know one of the choices to select under keeping a note hidden is “potential to cause harm.” Not sure what all the choices are I have not used this feature personally. We were told If we use it too frequently it will be flagged. 

This has been a reminder that we need to keep our notes objective. 

When we first went live patients were getting results to imaging and tests before a physician reviewed and was able to discuss... Now our system changed and any critical results do not post to the patient access portal for either 24 or 48 hours so that doesn’t happen. 

I know the details might be different for other places, but we have learned there are a few work arounds we can use while still being in compliance with the new law. 

[trytounderstand]

On 3/20/2021 at 9:26 PM, NurseLy said:

I know the details might be different for other places, but we have learned there are a few work arounds we can use while still being in compliance with the new law. 

So in other words keep the patient in the dark....recently know someone who would have had surgery if they had believed the first doctor they were talking to.....the reason why a question was raised by spouse was because they had received results from patient portal and knew what questions to ask....

While I agree that some patients and family members are over the top and many may pose a threat to themselves and others, keeping someone in the dark over their test results and findings is morally wrong and results in incorrect informed consent...Reporting someone as being argumentative or non-compliant because they do not want to take a medication that they know will actually make them physically ill is wrong...patients not having a system to request assistance from patient advocate is wrong....as in all things two personalities can clash in any situation and only having one side of the story documented and then to be able to hide those reports is morally wrong....

Patients or family members should have copies of the reports whether they understand them or not.  They should be able to ask any questions that they have and have them answered honestly.  They should have a list of medications that have been prescribed and be allowed to decline or request substitution without judgment. They are the ones who live inside that body and they should have the ability to make a choice.   

I do agree that at the time of the difference of opinion the patient maybe should not read what has been documented about them but there are always two sides to every story.  If the patient or family is not allowed to add their opinion or ask for help with a situation they feel is detrimental to their care, are they receiving the best medical care?  They should be able to ask for help without judgment and it should not affect the quality of their care...

 

[NurseLy, BSN, RN]

11 hours ago, trytounderstand said:

So in other words keep the patient in the dark....recently know someone who would have had surgery if they had believed the first doctor they were talking to.....the reason why a question was raised by spouse was because they had received results from patient portal and knew what questions to ask....

While I agree that some patients and family members are over the top and many may pose a threat to themselves and others, keeping someone in the dark over their test results and findings is morally wrong and results in incorrect informed consent...Reporting someone as being argumentative or non-compliant because they do not want to take a medication that they know will actually make them physically ill is wrong...patients not having a system to request assistance from patient advocate is wrong....as in all things two personalities can clash in any situation and only having one side of the story documented and then to be able to hide those reports is morally wrong....

Patients or family members should have copies of the reports whether they understand them or not.  They should be able to ask any questions that they have and have them answered honestly.  They should have a list of medications that have been prescribed and be allowed to decline or request substitution without judgment. They are the ones who live inside that body and they should have the ability to make a choice.   

I do agree that at the time of the difference of opinion the patient maybe should not read what has been documented about them but there are always two sides to every story.  If the patient or family is not allowed to add their opinion or ask for help with a situation they feel is detrimental to their care, are they receiving the best medical care?  They should be able to ask for help without judgment and it should not affect the quality of their care...

 

Notes should never be written with wording such as pt is argumentative and non compliant. An objective way to say the same ...  pt educated on xyz, pt declines xyz at the time. 

I am certain you can think of a time or two when the chart should be hidden, to avoid harm. Imagine the social worker finds out a patient can’t discharge home because a family member, who helped provide care at home, died. The social worker now needs to document discharge is delayed because adequate support is not available at home. (True scenario I have recently experienced.) The patient doesn’t yet know the family member died, because family wants to come in and tell them in person. We have a no visitor policy because of covid, so we are working through the steps of getting an exception to visitation approved... There are situations we run into, that information is documented that can cause harm, so we now can hide notes, rarely but when truly warranted. 

And if a patient has a test result they don’t need to panic about because the radiology report says something like “can’t rule out mass.” This is not clinically correlated to the patient. The physician may know it’s not a mass.  Or maybe further testing is warranted. That information is better delivered from the physician and it can be followed up with plan of what will be recommended next. And it needs done with in 24 hours.

I agree patients have a right to know everything about their care but timing is everything. Agree to disagree..

[trytounderstand]

16 hours ago, NurseLy said:

I agree patients have a right to know everything about their care but timing is everything. Agree to disagree..

I agree to disagree too.  As always there are exceptions to the rules.  There may be valid reasons to shield the patient or family members.  Also as I view any of my test results, I have common sense enough to know to wait until I can see my doctor with any questions.  I also have common sense enough to know that in doing research you do not believe everything that read on the internet.

I feel that if patients or family members should have the ability to reach out to a patient advocate.  If the situation is becoming overwhelming for either the patient or the caregivers it can be mediated at the time.  Perhaps with a better outcome for everyone....