Would keeping my own birth book be a HIPAA violation?

[somedayCNM, CNM]

I'm just starting out in L&D after two years in Med-surg and one of the books I read advises keeping your own birth book mostly to keep track of statistics and trends, but also as a memory keeper. This sounds very appealing to me, especially since I plan on becoming a CNM and will be keeping a birth log of sorts at some point in the future. My question to the forum is would you consider this a violation HIPAA even if I didn't keep names or other specific Patient Identifiable Info? I haven't started a book yet, but the information I want to record would be: initials and age of mother, G's & P's, time and type of birth, baby's sex, weight, length, apgars, pertinent interventions for mother and baby. What do you think?

[caliotter3]

Myself, I wouldn't do it. But that's me.

[Anna Flaxis, BSN, RN]

I'm not sure why you would do this. All of that info is in the chart.

[KimN]

I don't know ... that sounds pretty. scary. I can just imagine the looks from other staff members you will receive when they see you writing patient information down for your own records and then leaving the facility with it. I'm also not sure that keeping the mother's initials would do much good helping you statistically. It seems like once you are working on the floor for a while you will have a mental statistic library! :)

[DedHedRN]

That's weird, was the book written before hippa? Sounds risky.

[Flo., BSN, RN]

Thats odd. I can see keeping a running tally of the babies you deliver but to keep all that info sounds a bit much.

[traumaRUs, MSN, APRN]

No - would be considered HIPAA because its info you don't need to know except when caring for the pt/baby.

[Whispera, MSN, RN]

Why do you want or need to do this?

[CEG]

I am a CNM and I keep a birth log. Pretty much Same info as you listed. It's important for a provider to know/track their stats. It isn't a HIPAA violation, you aren't divulging the information to anyone else, it is information you have as part of doing your job, and you are not giving it to anyone else. You could even ask the patients' permission to put them in your log if you are really concerned about it. ACNM sells a birth log in the format you described. You just have to protect the info from falling into the wrong hands, mine is either in my office or in my home office.

[DebblesRN, ASN, BSN, RN]

I would check with your nurse manager and policy and procedure before I start that up. You do realize that if there is an issue with one of your patients that goes to court, and your coworkers know about this log book you keep, and they tell someone you have the book, an attorney can subpoena that, right??

I can understand a hospital, physician, or midwife--or a nurse doing research projects for the facility keeping a log like this, but to do it for personal reasons and have it at home?? I don't think I would do that personally.

The hospital keeps a log book of all that info anyway, so why bother?

[babyIT]

I worked L&D for over 20 years and I remember young nurse, just starting out, who planned on keeping a log of every patient she took care of. I remember asking her why she felt the need to do this, and her answer was along the lines of: in case there was a lawsuit, she would be better able to remember details. I was fortunate in that I never had to go to court because of a patient issue, but I did have to talk to risk management and hospital attorneys a few times about specific situations. Believe me, when you are given the patient chart to review, you will remember the patient, especially if there was an adverse outcome. Unless you are a midwife with your own independent practice, I think you should let the hospital worry about tracking stats and you just focus on taking care of the patients. Believe me, after a few months it will become harder and harder to keep your list current. There were times after a busy shift when I could barely remember my own name, let alone statistical details of a patient to be able to write them down in a log. With that being said, I think there is value in keeping a personal journal in which you document your feelings and thoughts, while keeping details which would identify patients out of the record. And of course, there are some patients who will be forever engraved in your memory whether you keep a log or not.

Best wishes to you on your new position.

[RNLaborNurse4U]

I did an experiment once: for about 6 months, I created a birth log similar to this. I only wrote the date, gender of baby, and vag vs c/s birth. This was simply to look at the stats of my own birth attendance. I wanted to see how many births I attended as an L&D RN each month, and what % were vag vs c/s. Is it discoverable if a lawyer find out I have this info at home? Yes. Will it help any lawsuit? No. Did I divulge any private info? No.

Needless to say, when I hit over 150 births, I stopped keeping track. I realized just how busy I am as an L&D nurse.