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Where can I find evidence-based practice data to support not using other patients’ names in medical records?

Monday January 28, 2013
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Question:

Dear Nancy,

I work in psychiatric nursing and when describing conflict between one patient and another in the medical chart, I believe the HIPAA best practice is to not use names. Where can I find evidence based practice data to support not using other patients’ names in medical records?

Neil



Nancy Brent replies:

Dear Neil,

There is a resource that might help you find evidence-based practice on the issue of using or not using other patients' names in nursing documentation. The Evidence-Based Nursing journal and its website (ebn.bmj.com/), have a wealth of information on evidence-based research.

It also should be pointed out that long before HIPAA and evidence-based research, a patient's right to privacy and confidentiality, especially in the psychiatric setting, was well established. When the need arises to document a situation between two patients in a psychiatric setting (or any setting for that matter), using initials of the other patients involved, or using a first name and a last initial is the safest way to protect privacy and confidentiality.

You might raise the question, of whether even the above way of documenting an occurrence when another is involved is an invasion of the other's privacy and confidentiality. However, remember if there is a lawsuit over a patient injury, it is essential the occurrence be described fully and accurately. The lawyer who needs to identify "P.G." or "Peter G.," is able to do so through established discovery methods (e.g., depositions, subpoenas for patient records).

Cordially,
Nancy




Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.