Worksheets--do you keep?

It was advised notes or a journal can be subpoenaed for a court case in the legal column of one of the nursing journals. All of one's notes or all of one's journal, not just extracted notes pertaining to the case at hand. Some nurses journal and use this info with their therapist. So, in this instance, one should be careful what one puts in their journal. This was discussed with my attorneys when they asked if I had notes when preparing for my deposition. At the deposition, copies of my charting were the focus of the deposition. The opposing attorney went over my charting, line by line. I was sweating throughout. When they tell you in school to chart for the courtroom, they know what they are talking about.

That's just scary. I don't write about anything about work in my journal, and that thing'd be in a bonfire before I'd let them take it from me and read it in court! YIKES!

I have a binder where i split (but folders) all my patients and the education reference/charts in the back.

At the end of my shift I take out the nursing Kardex and keep the patient's template worksheet (that I created)

When I come back the next day; if I do not have the patient I just throw those certain templates away.

However if I suspect any legal problems, or if there were any concrete problems I would save in my other binder where I have all my clean templates/organizational papers. Otherwise... trash them... they are pointless to keep.

I am extremely organized/anal/OCD :)

If I work the next day I will take them home but leave them in my bag because I will get the same patients the next day. If not then we have a basket where we put them and they eventually get shredded. eventually. ^_^

Be careful. If you take this information outside of the hospital, you can be in trouble according to HIPPAA. The chance of that is relatively slim however.

The idea that these "brains" will help you remember what happened etc. sounds good but a good prosecuting attorney will question their authenticity and whether they are original. (or did you just create them?)

Also, going back to chart something later (like several days later) is a red flag unless you chart a "late entry" and why you're charting several days later.

If something goes wrong during your shift and you're worried about a lawsuit, simply go home. Write down the events of what happened to the best of your knowledge, place it in an envelope and mail it to yourself via a certified letter. That way, it's dated and unless you open it, it's evidence of your interpretation of the events.

I don't use worksheets. Saves a lot of hassle. Fortunately I've been blessed with a good memory.

When I worked on the floor, I used to periodically "thin" my clipboard (once a week). My clipboard used to sit in my locker. :)

- Roy

Be careful. If you take this information outside of the hospital, you can be in trouble according to HIPPAA. The chance of that is relatively slim however.

The idea that these "brains" will help you remember what happened etc. sounds good but a good prosecuting attorney will question their authenticity and whether they are original. (or did you just create them?)

Also, going back to chart something later (like several days later) is a red flag unless you chart a "late entry" and why you're charting several days later.

If something goes wrong during your shift and you're worried about a lawsuit, simply go home. Write down the events of what happened to the best of your knowledge, place it in an envelope and mail it to yourself via a certified letter. That way, it's dated and unless you open it, it's evidence of your interpretation of the events.

Our computer system works so that if you're charting on a later day, you have to go in under "late entry" to be able to chart it at all, so it knows it's being charted late. If it's a narc, the times can also be checked against the Pyxis records. Vital signs and I&O's go on a handwritten form/graphic, so there's no way to know when anything was put on it, it just goes in to the time slot that it was done at. If they're not charted, obviously one time slot, like 8am on 4/30, would just be blank. It still can help to get a 24 hour total on I&O over a period of days if one day was put in late by accident...IMO better than to not be put in at all. It's not like charting late is a habit, like I mentioned, I never have actually had to go back and do it. I just like knowing that I CAN. Some of our docs get very, very upset if numbers from I&O's are missing, which is understandable, since I take care of surgical patients. I'd hate to come in and have a nurse go, hey, cherry, you forgot to chart so-and-so's 1600 VS yesterday." If my papers are gone, then I can't do it. It's just a little *insurance* for me.

I leave everything in my binder, and leave it at work on a designated shelf, then toss it all in the shredder on my next shift.

Tait