Judy states:
"We are trying to decide how we can both provide the info for the
chart and
also for our own records, without charting in two places or use a
sheet with
4 carbons,as we have to have a place for nursing to chart."

We used to have something we kept for our records, but learned that
this is a humungous "NO NO".  It is referred to as "shadow
charting".  If there were ever a legal concern and it was discovered
that info is in two different locations, apparantly  the question
can be raised that perhaps there was information that was being
"hidden".  Then there is all the HIPPA concern.  We were told that
EACH sheet we had in our office could result in a fine of several
thousand dollars!  The second part of the problem was that we
couldn't legally just toss them (even via a shredder).  We had to
swear that they were worksheets and contained no information that
wasn't duplicated in the permanent record.  Then they had to be
destroyed by Medical Records.  Med Records and our HIPPA expert did
agree that we can use TLC, but there are strict rules we have to go
by.  First we create the plan we give to the mom.  Then we
"incorporate" that plan into the full report.  We can print only 1
copy of the full report.  We fax a copy of that printout to the doc,
then it goes into the permanent chart.  Report to the doc must be
faxed, not sent by e-mail since e-mail can be intercepted, viewed by
others, etc.  We cannot add or change anything in our computer after
that.  Any additional info must be a new "contact".  We're just glad
we can use the program after spending the money for it.

Things were so much easier before there was so much paranoia
involved.  I agree that patient info must be kept confidential, but
much of the new regulations seem to have gone overboard.  You get to
the point when you wonder if you can call a patient by name without
violating some regulation!

Winnie

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