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Discussion

Transporting Nsg Notes

I'm working on a home healthcare case as an RN (I am pretty new to home health, btw) in which my place of employment requires nsg notes to be brought back to the facility for billing reasons. These are always written nsg notes btw. The parent of the pt is requesting that the notes stay in the house because it is a HIPAA violation to take them out. I've been searching for a little while online for the answer and haven't found anything involving my situation. Is this truly a hipaa violation to take them out of the home? The healthcare provider needs to be able to have a copy as well, correct?

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    It is not a HIPAA violation. Our nurse's notes are in triplicate & one copy stays in the patient's home. The other two copies go back to the office. It would only be a violation of HIPAA if you were letting outsiders read the notes. The agency has to have some way to prove nursing care was actually provided in order to get paid.

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    • Guides

    Our paper nurses notes are the same way as KarenfRNs (triplicate). They use the returned (we can mail or physically bring ours in) notes in the function of a time sheet as well as the medical record.

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    I do not work in home health so there may be intracacies I'm unaware of but in a very basic sense ... the nursing notes are part of the patient's medical record, which belongs to the agency providing care, not the patient. It is not a HIPAA violation for the agency providing care to maintain them, any more than it is for a hospital to maintain a patient's chart and not send it home with the patient upon discharge.

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    The parent is wrong...the notes may be removed from the home and transported to the permanent patient medical record.

    Having said that, you have a clear legal responsibility to safeguard those documents when they are in your custody. Any incidents with the data/contents of the form would be a HIPAA violation. Be sure to transport them in closed files or containers so that they are not visible (especially demographics) from outside your vehicle.

    Many of us purchase small portable file boxes for this purpose, among others.

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    • Author

    Thank you all for the responses and also the messages. They have been very helpful and raised my confidence in my initial thought. It is now on the table in discussion and hopefully something works out properly. Seriously, thank you all!!!

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    This boils down to a very simple issue. If the notes cannot be maintained by the agency providing care, they can no longer provide care as they would be in a big mess when the State or Feds came to do an audit!

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