Student nurse HIPAA violation question

by owenwither owenwither (New) New Student

Hello I'm a nursing student and I'm just wondering if it's a HIPAA violation that will get me expelled from my nursing program if I go back into my patient's medical record once they are discharged the day before. 

So out of 2 days of the week during clinicals, we get to choose 2 patients to write up on. So on the 1st day I was too busy helping my nurse so I didn't get to really research and write down information of my 2 patients to complete my paperworks. My nurse made it seem like my 2 patients weren't going to get discharged soon so I thought I can try writing my patients Diagnoses, Labs, etc for my paperwork the next day. However, the next day, one of my patients got discharged after I left my clinical shift. Would it be a HIPAA violation and would I get written up and reported if I go back and access their mr to finish writing their info for my clinical paperwork? 

Edited by owenwither



Specializes in retired LTC. 7,735 Posts

Ask your Medical Records person, but better still, ask the facility-designated HIPAA Coordinator. I think I remember that all HC facilities had to have one trained representative (?).

Put your request in writing with a simple explanation and ask for an OK. Get your response in writing. Altho your request is simple in its intention, DO NOT, I repeat, DO NOT, TAKE IT UPON YOURSELF TO ENTER THE MED RECORD WITHOUT PROPER AUTHORIZATION. Not even for your instructor, who like you, means no harm.

If you've been reading along here for a while, you will note that there have been several students/nurses found to have inappropriately opened the medical record. Their subsequent penalties have sometimes been quite SEVERE. 

HIPAA is federal law and facility reimbursement could be jeopardized. Serious BIG-TIME repercussions. Written up & reported? You could be expelled from school, and poss more.


Welcome to AN!


Edited by amoLucia



Has 5 years experience. 547 Posts

Don't go back into the medical record. It is better to get a low grade for the clinical day, a low grade on the assignment, look stupid you didn't get your work done, assignment half done, whatever, than to violate HIPAA and get kicked out. Don't do it.

I agree with the responses above. It would be a good idea to ask with your instructor rather than taking that risk. Best of luck!