Worksheets--do you keep?

I think this might be a HIPAA violation as well, the same as carrying home copies of labs, etc. We are supposed to document in the chart so that a clear picture will be there to remind us even years later. (HA!)

What exactly do you mean by "something happens"?

Are you asking if maybe it might be useful to have you report sheet if you get involved in a lawsuit?

I don't worry about that. I toss my report sheet in the secure bin that goes to the paper shredders after my shift is done.

My opinion is you should discard (appropriately) them unless you have a use for them, and once you no longer have them, discard them. If you keep some (for reference sake, or to "jog your memory") but don't keep them all, you may have a problem later on if you are sued for malpractice or subpoenaed for another purpose. If you have it, it could become evidence (and could either hurt or help you, but I personally bet it would hurt more then help,) and if you don't (because it's not one of the ones you chose to kept) they will use that as "evidence" that you are trying to hide something. Therefore, it's better to discard them all, and simply say "I may keep notes for my own personal use during a shift, but once my shift is over or care is complete, I log those notes into the computer and discard my personal notes in the shredder. Everything that was on my personal notes is reflected in my formal care notes." At least then you're only being held to one standard, and not whatever standard a trial lawyer wants to try to make up regarding your own personal notes.

I am not a lawyer. It was just something I've been told in the past, which made sense to me.

I put mine in the shredder at the end of the shift. That way, I don't risk breaching confidentiality by bringing home something with a patient's name on it.

I also do not pass my sheet on to someone the next shift because I have no control over it once it leaves my hands. I've annoyed some people by doing this, but I don't care. Our worksheets are printed from the computer and have my neumonic on it. If someone else leaves it lieing aroung, I'm the one who gets blamed.

I have also heard that if you keep them, they can be used in the event of a law suit. Of course, my hand writing is so bad, they have to bring in a code-breaker to read it!

I keep mine. I NEVER TAKE THEM HOME. I store them at work in my locker in a folder. I was told that if they are kept at work, they can be used as a legal document. Remember in nursing school we were told to keep a diary, this serves as the same purpose but it must never leave the job site! Think about it, it has vitals, meds,times, notes, etc... What a perfect diary!

I keep mine. I NEVER TAKE THEM HOME. I store them at work in my locker in a folder. I was told that if they are kept at work, they can be used as a legal document. Remember in nursing school we were told to keep a diary, this serves as the same purpose but it must never leave the job site! Think about it, it has vitals, meds,times, notes, etc... What a perfect diary!

That's what the chart is for. If it's important enough to need to be written down forever, it should be in the chart.

Yes, I know that is what the chart is for but I wonder if I will be able to see the chart when or if I end up in court. Our charting is computerized.

Yes, I know that is what the chart is for but I wonder if I will be able to see the chart when or if I end up in court. Our charting is computerized.

You will absolutely be able to see your chart. If your are the defendant or you are testifying for the defendant (and he has a decent lawyer, which I hope to God he does) they should make sure that you see the chart prior to testifying. Not that it will help you that much, 'cuz you would be amazed at how a lawyer can twist your words. If it weren't so evil sometimes, it would be amazing.

I don't believe in keeping them in the case of a lawsuit or anything like that (no way could I even store them, anway).

I keep my profiles for a couple of days, in my locker. I only do this so that if I forgot to chart a set of vitals in the chart, or the I&O, or the time of a PRN in the computer, I can go back and see what they were. At the end of the shift, I put my clipboard with my papers on it in my locker. By the end of the next shift, I pretty much know whether or not I forgot something (someone will usually~hopefully?~leave someone a note if they forgot to record something). I could, if needed, go back to that patient's profile for VS and put them in the chart. I don't know why I'm anal about doing this, as I can't recall a time that I've needed to go back to find something, but I just worry since I write my VS down (and all other pertinent numbers) on that sheet first, and once I toss it in the bin, it's gone. If I forgot to write them in and the next day realize it, it's too late and they're gone for good. So, it's just a little, temporary back up, and it makes me feel better. I don't ever take them home, though. They go in the locker for a few days, then they go in to the confidential paper disposal bin.