Do you take home your worksheet with information on it from your shift in case someone has questions or you forget to chart something you have your facts with you? The hospital I used to work for told us to do this. I was fired from my new job for doing this after being on the floor for two days! They said I breached confidentiality.
I wanted to do this as a poll but I did not get the prompts to fill in so I do not know how to do it LOL.
I thought I would move this topic to general discussion but I do not know how to move a thread either LOL.
Sorry, I saw this thread a few days ago and never got around to posting till now. All kinds of things go on at the place where I work. There are at least two nurses who keep there work sheets going back two years in their lockers. I am positive of this because they showed me them. Most people shred their work sheets at the end of the day. I keep mine in my locker as long as I have the same assignment. You see I am off long for stretches so my assigment changes complete and they are useless. When the assigment changes I shred. On two or three occasions I have had very bad shifts and when I got home I found them in my pocket. I took them back with me next time I worked and shredded them. Thanks for warning me to be more careful.
I leave my notes with names on them in my locker. Other notes with just room numbers I take home for questions if called. I mostly jot down all my good info on the nameless pages.... sorry about your experience.....
Wow, what a raw deal. I hope you like your new job.
I always kept my index cards when i was a staff nurse. I think i probably still have a pile of them somewhere.
Presently I keep a small notebook in my pocket and when i see a particular worrisome or challenging person i write down their name (last) room number and problem. This was especially handly when I learned to do procedures and i needed to keep track. Now i realize i've violated alot of HIPAA rules. I knew i should have paid better attention during that foolish movie !!
A bit of advice to add on to the young nurse who referred to her risk manager. If you have a particularly troublesome situation and you believe at a time there may be a liability issue and you feel the need to jot any info down...whatever you do do not write/transcribe it on hospital paper as that too is then considered entirely supeonable in a court of law.
Specializes in NICU, PICU, PCVICU and peds oncology.
I don't bring my worksheets home, since in the unit where I currently work, we don't use them. (I make notes in pencil in the treatment area of our critical care flowsheet as a reminder, erasing things as I do them.) I have, in the past on other units, accidentally gone home with a worklist in my pocket, found it when I emptied out the pockets and then shredded it.
However... if something happens on my shift that could potentially go to court, or if something has already happened, I will keep notes in a spiral notebook to help with memory later on. I put the date, no patient name or diagnosis, a chronology of events and what details I've charted, ie when the doc was called, when the doc responded, what the doc said, what else was said and what the end result was. I learned this method of self-preservation from my coworkers in the PICU in Winnipeg, Manitoba, which was a player in the longest running medical inquest in Canadian history a number of years ago over unacceptable morbidity and mortality in the pediatric CV surgery program. Those nurses were left to the mercy of the courts by their employer, but without exception, they all performed their professional duties and documented them in a manner that is above reproach.
I took in a sheaf of old worksheets from my files last week to be shredded and am bringing more in today. I'm very quiet about it so as not to call attention to what I'm doing. :chair:
It's still hard to shake off the feeling that I NEED to have these worksheets-- just in case. But I plan to do what a few others have posted: keep a notebook with pertinent info-- without names-- if I ever feel like something may come back to haunt me.
I've done this for the past 30 years, saving them for a minimum of 2 years (some hospitals longer!) and don't have any intentions of stopping now, HIPPA or not...My notes belong to me.
I have been an Agency nurse my entire career (35+ years). I take all my notes in my own spiral notebook, using it to take report, making my "to do" list, and noting all the things that I need to chart on (vitals, assessments, treatments, CBG's, insulins, PRN meds, etc...)
I write the Facility name, Unit I'm working, shift & Date at the top of the page. I use the notes from MY notebook to fill in all of the Facility's paperwork...24 hour sheets, chartings, etc. MY spiral notebook(s) always go home with me, and I have BOXES of them in the back of my closet. Years ago I took a class on "Laws Every Nurse Should Know"... and one of the points they made was...CYA !!! Keep your own notes! Fortunately, I have never had to go through my boxes looking for a particular happening on a particular shift...but I have had to refer back a week or so, to answer questions from an RCM regarding a certain diabetic alzheimer's patient who's husband was medicating her secretly. (Husband thought we weren't giving her enough insulin...pt. ended up in Diabetic Coma...) I was able to tell her exactly how much and what kind of Insulin I had given at what time, (from my home) without Facility's MAR in front on me. (I had, of course, recorded it in the MAR...but she was just "double-checking" on ME!)
Good luck at the new job Ren, sounds like the other place wasn't one I would have wanted to work at anyway!
I used to work in a facility that had NCR Nurses Notes- you know the kind with a white sheet of paper on top , and a yellow one underneath. When you write, the writing goes through, so you get two copies of your note. We did not continue our notes where the last nurse left off. We were required to get a fresh NCR form and start a new note with each entry.
I kept all my yellow NCR copies for years.
I recently went back and shredded them all. Not because of HIPAA, but because it has been ten years since I cared for these pts.
What a nostalgic trip it was to read back over those notes. Brought back some nice memories of some real sweethearts I took care of...and some not-so-sweet-hearts!
Whenever I write an incident report, I always keep a copy, and always will. If something happens because an employer is ignoring a problem, I want documentation to show that I have brought the problem to their attention. I have known of incident reports that get "lost" by a facility and I have been told "You never filed an incident report about that." I have been able to prove I did. I have a copy!
Renerian,
The way that hospital treated you was shameful. I imagine you are really stunned.
Tiki_Torch
208 Posts
One question: If your worksheet does not have a patient's name/room number or other personal identifiers on it, would this count as a HIPPA violation?