Please help settle debate about medical record/revoking consent

xtxrn, ASN, RN · Jul 30, 2011

Hello all, :)
If a patient voluntarily gives you a written copy of something pertaining to their situation (i.e. med. list, past history, etc.) with the original understanding that you can keep it for the medical record, can the patient demand it back? Doing so would remove that document from the medical record.
I would think that once something is given to the provider it becomes part of the medical record and the provider needs it for the legitimate purposes of number one, treating the pt. and two, explaining their rationale for the treatment that they provided.
Say the pt. gives me a photocopy of their med. list and then later they demand I give them the copy back...I would have no way to prove that the pt. stated in writing that their dose of Atenolol was 50mg/day when really it was 100mg/day and they were mistaken.
I have researched HIPPA, PHI and revoking of medical consent to find the answer and all I come up with is confused.
What do you think? Can a pt. demand their information back and say they are exercising their right to revoke consent?

Then xerox it and put the xerox in the chart....:smackingf

It's not really consent if you aren't doing anything. It's their piece of paper- give it back :) They are asked about meds and medical hx anyway. I don't see this as a consent issue....consent implies doing something. All that was 'done' is throw a piece of paper in a chart (or scan it in).

How do you revoke consent for a chart??...It may be his/her info, but it's in the hospital's record system. If he/she wants more than what he/she gave you, then they usually have to sign a release of information- that's not the same as consent.

JMHO....

gonzo1, ASN, RN · Jul 30, 2011

In regards to a med list: When pt comes into ER we ask them what home meds they take. And chart them. Most of the time the pt doesn't know the names, or the doses, etc. I will chart that pt "not sure of all meds, doses, frequency" If pt later tells me they are not taking something after all I just erase it from the chart and put a note that pt states they made a mistake on the med list and said med was erased. If pt hands me a list of meds I copy it and put the copy on the chart. If pt were to ask for the copy back I would give it to him.

Pt can consent to treatment, then can refuse any treatment, just chart pt declines CT scan, EKG, etc. I usuallly add that pt was educated on reason for treatment. Unless the pt is altered mental status they have the right to change their minds as much as they want. This can be a pain in the butt for us, but they have the right.

Also if a pt signs a DNR, they have the right to change to full code at anytime

Hope this helps

xtxrn, ASN, RN · Jul 30, 2011

I have an extensive medication list that I couldn't recite at will any time I needed to, so i carry a list in my wallet along with the diagnoses for each... Usually (don't have a current list in this computer yet) I will make a copy to GIVE to the office/ED. If I haven't been able to get a copy, I let them copy it and get my original back. :nurse:

GHGoonette, BSN, RN · Jul 30, 2011

I presume there is a questionnaire that has to be completed on admission; that's pretty well standard. Space for you to record medications, food preferences and/or allergies is provided in most of those that I have seen. Once it is completed, it becomes part of the legal documentation, so you shouldn't have any need to retain any lists handed to you by the patient. That is his/her property and you can return it.

Hospital records, charted on hospital forms, remain with the patient's folder.

MrChicagoRN, RN · Jul 31, 2011

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Then xerox it and put the xerox in the chart....:smackingf

That should cover it.

However, if the patient demanded it be removed from her chart altogether, that would be a different issue. IMHO, once it's in the chart it becomes a part of the legal document, and a copy of it should remain in it.

bjaeram · Jul 31, 2011

A photo copy will do

I always give the list back. If you don't I guarentee they won't have it next time. Iv'e had people say I had a list but so and so kept it. Give it back so they have it!

ERnurse2001 · Sep 22, 2012

However, if the patient demanded it be removed from her chart altogether, that would be a different issue. IMHO, once it's in the chart it becomes a part of the legal document, and a copy of it should remain in it.

Yes, this was my point and I think you were the only one who understood that.

I wrote that it was a copy that I had, I gave them the original back and then they also wanted the copy back.

This created a problem because although the med. list was entered into the computer, the patient or family later decided something wasn't right and I didn't want it to look like I had entered the information incorrectly. The written copy was the proof that the dose in the computer was what they said it was, not that I had entered the information incorrectly.

NayRN · Sep 24, 2012

I always copy their med list (with a photocopier) and give it back. I enter the meds into the computer manually (double checking that they are correct).

I happen to know that my hospital has a policy about patients disputing/having information removed from their medical record. At that point, it is not your responsibility. Removing/destroying documentation could be a big legal issue.

Refer them to the med records department, and let it go.

When reconciling home medications, mistakes are often made. Even calling their pharmacy to verify isn't always foolproof, because they could use more than one pharmacy. We do the best with the information we are given, and life goes on. I try very hard to make it clear to patients that they do have at least a little bit of responsibility when it comes to their medical care.

Nurses are simply not omniscient.

mariebailey, MSN, RN · Sep 24, 2012

I love copy machines.