Guest309671

I am a new grad nurse in my first year working as an RN. I learn a great deal every day, and want to track my progress and accomplishments. I want to be able to look back a year from now, whether I'm in a yearly review at my current position or interviewing for a new opportunity, and discuss specific accomplishments, strengths, and areas for improvement. So, for the past month or I've been writing a few short sentences after every shift about what I learned that day. We're talking paper/pen/notebook journal. For example, "Learned how to administer [antibiotic] I'm" or "Received positive feedback about [thing]." It's been helpful in internalizing a sense of competency and accomplishment, and combating that sense of Impostor Syndrome that new grads tend to feel. However, I want to make sure I'm on the right side of the law by doing this. I've been reading threads on here about the legality and ethics of keeping a journal as a nurse, and it sounds like there's issues with HIPAA and issues with journals being called into evidence in legal cases. Could a skills journal like this come back to bite me? I wouldn't want my reflections on my skills, obstacles, or shortcomings to become legal fodder.

There's quite a story that goes along with this one. Names were changed, of course. I'm a CNA at a retirement home, and this particular night I was working the evening and noc shift. There's a very sweet and mildly demented lady who lives in the facility. She's civil and quiet and kind, but doesn't remember what she ate for breakfast! On this day we didn't see her at dinner with the other residents. Since dinner is usually the best time to pass meds, we missed giving her her pills. We go up to her room and knock on the door. "Marie? Ms. Marie?" I turn the knob and walk in to hear her say "Oh no honey wait!" Ms. "Marie" is standing near her bed stark naked, with TWO sets of clothes neatly folded and placed on a nearby chair. "Just a minute honey!" she says. I withdraw myself from her room just in time to see a second pair of manly legs moving around in her bed. I was stunned, but after thinking about what I had just scene I dissolved into giggles at the mental image: two short little old people taking off their clothes and neatly folding them and putting them to the side before copulating awkwardly. Of course I HAD to tell my coworker on the night shift. She was OBSESSED with finding out who she had slept with. Watching her the whole night was funnier than the scandal between Ms. "Marie" and her companion. She looked for EVERY excuse to try and check in and see who the mystery man was. Finally, after a night of wondering and guessing, we saw Ms. Marie on her way to breakfast in the dining room. My coworker stopped her and gushed, "Marie, who was your visitor last night? I'm dying to know!!" Marie looked at her very innocently and said, "I don't know honey, but he was very clean."

I guess I must be a new nurse...:imbar