Someone in my charts....

[Maevish]

I'm a traveler for the time being, but I've never had this problem before (on staff or traveling): This is a really small ICU and there're only ever two of us here at a time so it's been an adjustment (no legal breaks, no help, etc), but one thing is really starting to irritate me.

With the exception of two people, the nurses I work with are always in my charts. This is one of many examples I could give....A coworker refused an admit because he had a "newly extubated pt" (he was stable and had been since extubation about 14 hours prior) so whatever. I was a bit annoyed, but said nothing and took it. Then he got bored, I guess, and I see him scrolling down a progress note that belongs to one of my patients.

I'm pretty sure this isn't right so I asked him if he needed anything or wanted to take the patient. He was clueless at my passive aggressive play:inlove: and said he didn't want the pt, but kept on browsing the chart. I asked him to get out of it, please, and he did, but has continued to do it this whole contract so far (except tonight). This is only one incident and it's not just him, but I've never thought of going through someone's chart just because I can. If I'm not breaking someone and giving meds or helping with an admit, I don't see what's so hard about minding my own business.

This was a bit of a vent, but I thought that was a HIPPA violation as the nurses didn't have anything to do with the patient care of my patients at those times. I was thinking of reporting it or at least telling the manager (on my last day lol), but I want to make sure I'm not going overboard. I've never had to even think about this before cause it was always legitimate, either I was in someone else's chart because I was passing meds or vice versa.

Now, this place is SUPER slow (not a real ICU...I've only ever seen 2 vents since I got here and they weren't mine lol) so I get the boredom, but I didn't think it was ok for people do to this. Watch YouTube videos or practice your British accent, or troll Allnurses.com, just stay out of my charts!!

xo

[gonzo1, ASN, RN]

Everywhere I've ever worked this would be a huge no no. I myself rarely look at another persons chart and then only if I have something to do with that patient. Working ER I was in other patients charts because we would routinely do meds, or casts etc. In the ICU it is more rare.

I actually live with the fear of being in trouble for doing this, but do look if it's appropriate for me to do.

I have accidentally looked at ER pt charts while in the ICU because I thought I was getting the pt and then I don't

You will not get into trouble for someone else being in your chart, that is all on them. As far as reporting it etc, maybe I would tell them to stay out, but not report because you will be leaving soon anyway and you won't be able to change the culture of a unit during your 3 month stay. I used to do travel nursing and the charge nurses and other nurses were often in my charts to make sure I was charting per their norm. Did I like it, no, but I really didn't care because I chart pretty good. Have never been told my charting wasn't right.

[canigraduate]

That is a glaring HIPAA violation.

Chart surfing is illegal. Full stop.

If he has no need to know to complete his job duties, then he has no business being in that chart.

Part of the HIPAA laws requires there to be a compliance officer. You need to find out who the compliance officer is and report it to them, not the manager. The manager will likely cover it up if it is accepted unit practice.

Every place I've worked that have EMRs have signs posted that chart access is tracked and audited. If you have no reason to be in someone's chart, that is grounds for immediate dismissal in most hospitals and can result in legal repercussions, including fines and -- brain fart, whatever it is that they do to your license where you keep it but there are notes about you doing something stupid and wrong. Encumbrances?

I don't know how much more I can stress this, but IT IS FEDERALLY ILLEGAL AS WELL AS UNETHICAL to be in a chart when you have no need to do so to complete your job duties.

[imintrouble, BSN, RN]

Our managers are pretty reasonable about the whole HIPAA thing. I'm allowed to access any chart on the unit I work, on the night I work.

I might start an IV or foley on a patient for a nurse who's too busy to do it themselves. Or give a PRN to a patient whose nurse is on break.

There are lots of reasons I need to access charts other than the patients I'm assigned.

I sometimes access an ER chart before a pt arrives to the floor, if that patient is mine.

Our facility is pretty laid back, but other area hospitals routinely fire nurses for HIPAA violations.

I don't usually read chart notes for fun, and can't say I've seen other nurses do it either. If I did it wouldn't bother me. I might ask what's going on, but just for curiosity. Not out of any kind of moral outrage.

[Been there,done that, ASN, RN]

P.S. They are not YOUR charts. They are the patient's charts. I worked a small ICU.. if I felt the need to access any patient's chart in the unit during my shift , it is MY responsibility to do so. I was responsible for ALL the patients in the unit if and when the assigned nurse was off the unit.. or too busy to attend to their assigned patient.

[Rose_Queen, BSN, MSN, RN]

Looking at other charts is most likely the norm in this unit, not just directed towards travelers. Doubt it is a HIPAA violation.

You need to knock off the passive -aggressive response. Reporting something on your last day.. might come back to bite you.

Just because "everyone does it" does not make it right. Unless the nurse in the chart has reason to be involved in care (including chart audits), he/she has no reason to be looking. If care is provided, that's different. Nosiness/curiosity/"everyone does it" is not an allowable use per HIPAA.

[NICU Guy, BSN, RN]

On my unit it is expressly forbidden to access a patient's chart if you are not providing direct care. They have a feature on EPIC that gives a warning and everything if you accidentally click on the wrong patient.

We also use EPIC and have a "Break the Glass" feature that alerts you that the patient record is restricted. You have to choose why you are accessing the record (direct patient care) and enter your password. There is no way of accidentally accessing the record.

[Julius Seizure]

I worked a small ICU.. if I felt the need to access any patient's chart in the unit during my shift, it is MY responsibility to do so. I was responsible for ALL the patients in the unit if and when the assigned nurse was off the unit.. or too busy to attend to their assigned patient.

I agree with this concept. Now, I dont think that it necessarily sounds like that was what this nurse's goal was in accessing that chart. But it would be very hard to prove that he was just being nosy vs. being prepared to assist the patient if the assigned nurse wasn't available.

[MunoRN, RN]

There are certainly some nursing environments where teamwork just doesn't ever happen, but for the most part in my experience nursing is a team sport, in which case other nurses aren't only allowed but often expected to look up basic info on patients in their vicinity since it's quite likely they will be involved in the patient's care in one way or another; either assisting in direct care or collaborating with the assigned nurse in some way.

[quazar]

We also use EPIC and have a "Break the Glass" feature that alerts you that the patient record is restricted. You have to choose why you are accessing the record (direct patient care) and enter your password. There is no way of accidentally accessing the record.

Yes, this is exactly what my hospital does. No browsing of charts "just because." You have to prove the need. Charge nurses or house supervisors I can see the need. Coworkers who aren't supervising? No.

[Spidey's mom, ADN, BSN, RN]

I just started a new job with a large dialysis company and had to go through all of the federally mandated HIPAA training just yesterday. it is a violation of HIPAA for anyone to look at PHI of a patient unless they are assigned to give care to that patient or otherwise connected, e.g., a unit clerk needs to fax someone's labs to their physician's office. Based on what the OP said, this other nurse had no reason to be in this patient's chart, and we can only go by what she said in this case.

I have never had a job, at least in the past decade or so, where this being a huge HIPAA violation was not stressed in the training phase. Companies take this behavior very seriously, and I have seen people get fired for it.

This is my understanding as well. Actually, all the way back to nursing school.

[mmc51264, BSN, MSN, RN]

We use EPIC too and not all pts have the "glass". I do blood glucose audits, so I am in charts but, I have a reason to be there. I know it can be boring some nights, but chart surfing is a big no-no.

[NotAllWhoWandeRN, ASN, RN]

Our managers are pretty reasonable about the whole HIPAA thing. I'm allowed to access any chart on the unit I work, on the night I work.

I might start an IV or foley on a patient for a nurse who's too busy to do it themselves. Or give a PRN to a patient whose nurse is on break.

There are lots of reasons I need to access charts other than the patients I'm assigned.

I sometimes access an ER chart before a pt arrives to the floor, if that patient is mine.

Our facility is pretty laid back, but other area hospitals routinely fire nurses for HIPAA violations.

That is clearly not a HIPAA violation, though. If you provided medical care to a patient, that's a valid reason to enter their chart to document the care you provided. If you will be assigned a patient, that is a valid reason to enter their chart to check for information you'll need to take responsibility for their nursing care.

Going into a patient's chart when you are not assigned their care, are not documenting anything you've done for them, are not doing chart audits, and will not be assuming responsibility for them in any way.. that clearly IS a HIPAA violation.