Potential HIPAA violation??

raindrops1234 · Jul 25, 2017

When I was a nursing student, we were told to go through our patient's charts to help with our research and getting to know the patient/develop a care plan (this would ultimately include ED notes if there were any).

RNNPICU, BSN, RN · Jul 25, 2017

If you were told to look up information on your patients then it is not a HIPAA violation from what you have stated. ED visits are part of the medical record. Why did you look in the ED visits?

For example....If you were clearly told "DO NOT EVER ACCESS ANY ER/ED INFORMATION UNDER ANY CIRCUMSTANCE" and then proceeded to access ER information, that would be concerning.

From your post it seems as though you were looking for data and had access to the charts to look for data, that is not HIPAA, unless there is other information you are omitting

JKL33 · Jul 26, 2017

Access to parts of the record is limited to what is the minimum necessary to perform your role/task. You were working on something assigned by the employer but unless you were assisted with your task by looking at the ED record, your employer would likely say that you shouldn't have. As an illustration, say a Registration employee is tasked with reviewing whether or not ___X___ Registration function was performed on all admitted patients, such as, say, signing Admission Consent. Should they be reading the ED record? No.

Most places I've been, they applied the "minimum necessary" guideline to employees.

Minimum Necessary Requirement | HHS.gov

Get in the habit of asking yourself WHY you need to access the area of the chart you're about to access. If it's for personal interest - - well, that violates the spirit of the law, right? Do it at your own peril.

I think you should say nothing and NEVER do it again.

psu_213, BSN, RN · Aug 20, 2017

By ED records do you mean the nursing documentation and/or ED physicians note? I would argue that those are critical to treating the pt. How did they present to the hospital? What S/S were present when he/she first got to the hospital? Even past ED records can be of importance. For example, if your patient is in the hospital with a CHF exacerbation, does this presentation mimic a previous presentation for CHF? Did the pt report an increase in edema or SOB before each presentation? Did he/she stop his/her Lasix before presentation? I would think that to be quite important for pt education. There is really no reason to "snoop" into an ED visit for, say, STD treatment, but other ED notes could be very important.

JKL33 · Aug 20, 2017

By ED records do you mean the nursing documentation and/or ED physicians note? I would argue that those are critical to treating the pt. How did they present to the hospital? What S/S were present when he/she first got to the hospital? Even past ED records can be of importance. For example, if your patient is in the hospital with a CHF exacerbation, does this presentation mimic a previous presentation for CHF? Did the pt report an increase in edema or SOB before each presentation? Did he/she stop his/her Lasix before presentation? I would think that to be quite important for pt education. There is really no reason to "snoop" into an ED visit for, say, STD treatment, but other ED notes could be very important.

No. She already stated that she accessed records that did not pertain to what she was doing. That's the end of the story in this particular case.

iluvivt, BSN, RN · Aug 20, 2017

OP... Please explain in detail why you were in the patients chart. What was your goal ? That will tell us if you violated HIPAA. Nurses and those caring for patients need to know the complete medical history and all current problems. If you are providing nursing care for the patient then you can most likely access the ED record . I have found that often something very significant is only mentioned in the ED record.Also there is often a delay in getting a current H and P on the chart or a certain speciality to come and see the patient and the ED record can fill in the gaps.