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?
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 just have to protect the info from falling into the wrong hands, mine is either in my office or in my home office.
Exactly as she says. You could have the log tattooed on your ass, and HIPAA wouldn't care. HIPAA cares about who you disclose the information to, not what information you keep. You would have to take reasonable precautions to prevent an accidental or unintended disclosure though (meaning you should keep it secured somewhere).
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??
However, as Debby says--your hospital probably has a policy against this behavior as part of their HIPAA compliance plan, therefore while it's not a de facto HIPAA violation, it would be against policy and could subject you to discipline if someone at your place of employment felt it was inappropriate. It would also be discoverable if there was some sort of legal action.
I wouldn't use the initials or any other potentially identifying info. If someone blabs that you have that journal and something goes to court (remember, you are in a highly ligated area and they have 18 years to bring suit)they could subpeona that journal and the hospital will toss you to the curb. All they need are the date and the initials and bang...there you have it. Better safe than sorry.
But why would it matter if the birth log were used in court? It contains statistical information that is already in the record. A journal where you describe the delivery with or without the minutae (stats, etc) would be far more troublesome if it described malpractice or deviation from protocol..
Is your intent to keep track of your growth as an L&D nurse? Rather than a log, what about a journal that you could write in after your shift once you get home to reflect on your own performance as a nurse. When I was a new grad I kept a journal for the first 5 or 6 months and it was really helpful to go back and read to see how much I had grown in that short period of time. I didn't really record any pertinent information about my patients, nor did I include names of staff or physicians I was working with - just my own reflections of my own performance in different situations.
Specializes in L&D, OR, postpartum, pedi, OBGYN clinic.
If there are no names, then you could keep a log. In L&D we had a written log at work adn the nurses would have competitions to see who had their name most in the book
But why would it matter if the birth log were used in court? It contains statistical information that is already in the record. A journal where you describe the delivery with or without the minutae (stats, etc) would be far more troublesome if it described malpractice or deviation from protocol..
Thank goodness I'm not experienced in medicolegal proceedings, but I'm just wondering whether an attorney could identify certain practice trends from this type of log and use them against the nurse. Maybe the nurse has a run of several kids in a short time who have poor five-minute Apgars. Or maybe the case in question involved an intervention that the nurse had not performed in a year. I know that handwritten personal notes have factored into cases before, but I wonder how many times this type of log has come into play in litigation.
astn
55 Posts
Exactly as she says. You could have the log tattooed on your ass, and HIPAA wouldn't care. HIPAA cares about who you disclose the information to, not what information you keep. You would have to take reasonable precautions to prevent an accidental or unintended disclosure though (meaning you should keep it secured somewhere).
However, as Debby says--your hospital probably has a policy against this behavior as part of their HIPAA compliance plan, therefore while it's not a de facto HIPAA violation, it would be against policy and could subject you to discipline if someone at your place of employment felt it was inappropriate. It would also be discoverable if there was some sort of legal action.