Log/diary/dayrunner...got one?

mycrofft

mycrofft

Still crazy but elsewhere
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Richard Nixon aside, I think it makes some hard sense to have a real professional diary. Mine (I keep it sporadically) has come into real play when asked about when and what happened involving whom, they have the record and I don't.
(Also, bringing that nice Franklin planner in and taking notes as they are talking to you gives you a one-up by nonverbally announcing you are serious and taking names. You can usually buy good looking binder for them cheap at local used stores...).
So what do you do to "memorialize" incidents?
(EMTLIFE posts?B))
 
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They're called Run Reports or Patient Care Reports (PCRs), and I make a habit of writing one for every run I'm assigned to.
 
Hastings said:
They're called Run Reports or Patient Care Reports (PCRs), and I make a habit of writing one for every run I'm assigned to.
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LOL!


I think when you start keeping a detailed log of your own at home, it becomes a privacy issue. Anyone could obtain patient info at this point.
 
jochi1543 said:
LOL!


I think when you start keeping a detailed log of your own at home, it becomes a privacy issue. Anyone could obtain patient info at this point.
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I keep a little steno pad with me and basically devote 1 page to every call I go on. I never use identifying information on it, but will note things said, vitals, etc just as I do on a PCR. I hate making mistakes and having to cross out on my narratives, so I use my notepad to write things down on scene and so that I do not forget anything when I show up to the hospital and write my report. It's come in handy, plus it lets me refresh my memory pretty easily if I ever want to review a call I found particularly interesting.
 
Buzz said:
I keep a little steno pad with me and basically devote 1 page to every call I go on. I never use identifying information on it, ...
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Buzz is pretty much right on about the privacy issue. Just keep any identifying factors off the journal that may link to a particular patient's PHI and that should keep you in the clear.

As for me, I carry a small Olympus digital voice recorder in a small case on my belt. Great for recording interviews and getting photo caption info since I don't know shorthand. Also, if I feel I'm getting into a compromising situation, I just reach down and click it on.
 
So let's just say you get stuck going to court over a call that happened years ago. They give you your PCR to review and you don't even remember doing the call. During the proceedings they ask you about something that isn't on your PCR and you don't remember. Why is it such a big deal for you to not remember something?
 
karaya said:
As for me, I carry a small Olympus digital voice recorder in a small case on my belt. Great for recording interviews and getting photo caption info since I don't know shorthand. Also, if I feel I'm getting into a compromising situation, I just reach down and click it on.
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I know of a medic around here who carried a recorder in his shirt pocket all the time (it looked like a pen) for about 7-8 years and only got called to court once the whole time saved his but too cus the call was over a 6 months ago. shoot i can hardly remember what i did last week, lol

and under Georgia law as long as one person (the person recording) knows that a conversation is being taped it is legal.
 
Some states have different laws about recording. But back to paper...

Yeah, gotta watch HIPPA stuff. However, I've seen instances when people were called in to their boss's office and confronted without the luxury of the run report or whatever one's agency calls it. Telling someone you "have no independent recollection" of something is a good response, but adding "I can bring in my personal log if you allow me" will force their hand, and sometimes defuse it right there. Plus if you write down the unique serial number for that run report you can ask for it by that number.
Your lawyer or union rep will love you.
 
Nope, no way, no how.

First of all, the PCR is the legal document. If they want to call you on something in it, they need to provide you a copy of it.

Secondly, if you have your own "personal notes" (setting aside any HIPAA issues), and you do take them into court then the WHOLE book goes into evidence and you can be questioned on ANYTHING in it. This can become a double edged sword.

Thirdly, why do you feel the need to keep a personal record? If it's important enough for you to keep track of, it's important enough to put into the PCR.

That's just my $0.02 worth...anybody got change for a nickel?
 
Yup HIPAA, I always screw that up and someone here will always correct you.

Good point, counsel can require that any notes you use in court be admitted into evidence.You don't bring it into court, but if you do you have your own copies made first and kept at home.

There is no requirement for anyone to provide you a copy, they ask "to the best of your recollection". (Hence "I have no independent recollection"). I've seen and had entire pages of documentation fail to stay where it was supposed to when a superior or a coworker were at risk and they had access to the paperwork. I've worked in an environment which over twenty years has at times been that adversarial and cannibalistic. I even took 2.5 yrs off and waited for the grand jury to scrape off a crew of them before I came back at the dept's invitation. That's how I've become the longest serving member of the entire dept...rather like the joke about second prize being TWO weeks instead of ONE at your destination, sometimes.

I'm just curous if other folks do any independent record keeping.

 
Yup.

I record on my little note pad the serial number of the PCR, vitals, SAMPLE/PPRRRST, and things said that are worth noting.

Don't put pts age, gender, name, address, race anything that could "violate pt confidentiality". In addition to that I wrote in black sharpie on the front of the note book: CONFIDENTIAL - CONTAINS SENSITIVE INFORMATION. That way if anyone reads it, at least there was some sort of message on the front.. just another way to semi protect my butt. But then again, the note pad stays in my jump kit, and no one goes in that while at home or anything.
 
I keep a log of my own, of interesting and important cases at work, and all cases when I am on call on the college campus. I write what is reported to the school newspaper, and my own patient care details, relevant details, never including information that would specify who the patient is.
I write something to the effect of:
20 y/o F, C/O SOB x 3days, O2 nrb, nc didnt improve, ?PNA?, bc meds, all to common ab, worried about final, ALS->hosp.
 
traumateam1 said:
In addition to that I wrote in black sharpie on the front of the note book: CONFIDENTIAL - CONTAINS SENSITIVE INFORMATION.
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Sorry that's a little bit like don't push the flashing red button. When someone sees that it will entice them more to read it.

As for records i don't keep pt info. But in the work field, anytime someone says something that could be brought back later on gets recorded. The feeling of going into a meeting and pulling out your contemporaneous record and then asking them to site theirs is a great one.
 
mycrofft said:
Yeah, gotta watch HIPPA stuff. However, I've seen instances when people were called in to their boss's office and confronted without the luxury of the run report or whatever one's agency calls it. Telling someone you "have no independent recollection" of something is a good response, but adding "I can bring in my personal log if you allow me" will force their hand, and sometimes defuse it right there. Plus if you write down the unique serial number for that run report you can ask for it by that number.
Your lawyer or union rep will love you.
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quote by ffemt8978
Secondly, if you have your own "personal notes" (setting aside any HIPAA issues), and you do take them into court then the WHOLE book goes into evidence and you can be questioned on ANYTHING in it. This can become a double edged sword.
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HIPAA is only one set of regulations. The chance for your state's patient privacy laws to get you is way more likely.

As ffemt8978 stated, if it is discovered that you have a notebook, it can and will be requested by the other attorneys. Whatever you have written can also go against you as well as assisting your memory.
 
While reading my book for class, one of the things it emphasized that if it is not written on the PCR (or whatever) then it did not happen. So what I can see coming back and biting you is if you bring up something from a personal notebook the attorney could ask why was that not documented? Or why was that information omitted from the PCR? Attorneys can be very manipulative (I know my mother is one... :glare: )

Just my two cents.
 
FireWA1, good point!

Lots of good points.
As I was walking in to work today, I was reflecting how a paperless medical recod system is so much more secure against the vagaries of psucho coworkers and bully-ish "superiors".
Just post about it here......;)
 
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PS: re. "If it wasn't charted it didn't happen"?

As I asked my last nursing instructor, "So I can push three CC's of regular insulin and if I don't chart it, it didn't happen?".
More precisely, from experience, if someone doesn't chart it, it might happen twice.<_<
 
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