Bringing home notes on pt. care??

I am currently a nursing student and CNA. During nursing school I was told from a clinical instructor that she takes notes home on her patients. She told her story about a recent legal investigation done on her job concerning a patient she care for many years ago. All of the nurses who had taken care of this patient were being questioned as well. The instructor said she had to jog her memory about ALL the care she had given this patient during their stay at the hospital. She was able to conjure up some info. In the long run she was not found at fault for any wrong doing to the patient. She said its best to make notes, take them home, and file them away just in case some legal actions are in pursuit in the future. The instructor is not the first nurse I have heard say this.

My questions: is this legal and to what extent? What can be documented legally and taken home? Is this a HIPPA violation? Is the note a SOAP, SOAPIE, ADPIE, etc note? I need clarification.
If it is so significant that it influences legal proceedings, why not just document it in the patient's chart in the first place?I do not understand keeping personal notes on patients for legal protection. If one were to keep them anonymous, one would have to put initials, pseudonyms and basically anonymize the data to the point where a lawyer could question whether the note actually referred to the patient or incident the nurse claimed it is about. If they are so specific that it could influence a legal decision, would the nurse get in trouble for keeping such sensitive data at home where he or she may not be authorized to keep patient information? And, again, why not just document it appropriately in the chart or report to management?

agree with pp. Seems keeping a mountain of info at home to jog one's memory "just in case" of a lawsuit is paranoid and unnecessary, not to mention that it does indeed cross the boundaries of pt. confidentiality. Always be in the habit of charting well and let your charting speak for itself.

Quote from CuddleswithpuddlesIf one were to keep them anonymous, one would have to put initials, pseudonyms and basically anonymize the data to the point where a lawyer could question whether the note actually referred to the patient or incident the nurse claimed it is about. And, again, why not just document it appropriately in the chart or report to management?

"She said its best to make notes, take them home, and file them away just in case some legal actions are in pursuit in the future. The instructor is not the first nurse I have heard say this."I have to wonder about your instructor (and anyone else who thinks this is a good idea). Miscellaneous notes on hundreds, THOUSANDS of patients filed away in your home? Private medical information about strangers that is not protected from anyone who stumbles across it? Ridiculous.If you do somethat that warrants charting, CHART it. Don't squirrel it away in your house! I can only imagine seeing a warrant for the searching of an entire home for any nurse who is suspected of keeping such information "just in case". And a warrant would absolutely be issued, because the nurse herself had made it known that she kept private medical info on her patients "just in case". As in "just in case the prosecution wants it"!Chart what is valid to chart. Take home ZILCH.

Quote from psu_213We had a similar discussion on here before about this. I believe those who know more about the law and courts than I do told us that if it is discovered that you are keeping notes of you own about pt care, and you are using that information in your testimony, then said documents could be entered as evidence. If this is true, I could see how this could cause someone who is peripherally involved in the case to be accused of wrong doing and be thrust into the center of the case.

Quote from RNsRWe"She said its best to make notes, take them home, and file them away just in case some legal actions are in pursuit in the future. The instructor is not the first nurse I have heard say this."I have to wonder about your instructor (and anyone else who thinks this is a good idea). Miscellaneous notes on hundreds, THOUSANDS of patients filed away in your home? Private medical information about strangers that is not protected from anyone who stumbles across it? Ridiculous.If you do somethat that warrants charting, CHART it. Don't squirrel it away in your house! I can only imagine seeing a warrant for the searching of an entire home for any nurse who is suspected of keeping such information "just in case". And a warrant would absolutely be issued, because the nurse herself had made it known that she kept private medical info on her patients "just in case". As in "just in case the prosecution wants it"!Chart what is valid to chart. Take home ZILCH.

Quote from 2bAngilRNI do not believe it is private medical information. I believe she made notes on the care she gave to the patient.

Quote from 2bAngilRNI believe if doctors orders were not carried out or medications not given based on her critical thinking skills she wrote personal noted for her own record.

Quote from CuddleswithpuddlesI see. What happens if lawyers ask for my entire stash of notes? If I volunteered one snippet I felt was relevant to my (or their) case, could I be ask to turn over all of it?

Quote from 2bAngilRNI do not believe it is private medical information. I believe she made notes on the care she gave to the patient. I believe if doctors orders were not carried out or medications not given based on her critical thinking skills she wrote personal noted for her own record. From reading the responses I need to get in contact with the instructor for further clarification.

Quote from psu_213I'm not exactly sure of what exactly has to be turned over (I'll leave that to the more legal-system savvy on here), but consider this scenario:Attorney: "You stated that you turned bed alarm off because the patient requested it not on and that they promised not attempt to get out of bed. How do you remember that from 5 years ago when it is not in the chart? Did you happen to keep notes on this patient?"Nurse: (under oath) "Yes, I keep pertinent notes about patient care and keep them in a safe place in my house."Attorney: "So, you are telling me that you keep notes on patients at your home? Are you not aware that those notes contain confidential information that you have now put in a place where others can stumble across it?"Nurse: "I don't identify the patient on those notes, just refer to them by initial."Attorney: "I see. So your notes at home have the initials "L.O." on them for my client Lauren Osborne? What if those are actually your notes on Louis O'Brien?"It just isn't worth keeping notes and can cause a lot more trouble than they are worth.

Quote from Here.I.StandBut for her to remember who said note was about (out of possibly thousands of pts per year), she would have to have their name, date, etc. to even remember who she was talking about. When I was in school, a classmate said an RN she knew took her brain sheet home every and filed it--just in case she were to get sued. This was during the "get liability insurance" lecture. Our instructor who did LNC work part-time responded "NO. That is a HUGE HIPAA risk to have all of that PHI in your home."