At my last job part of my duties was random auditing of medical records. As an RN I am sure you have heard the line of "not documented, not done". So that was my job. I would run a computer program of randomly selected medical records. I generally never even got a persons name, just the medical record number of a patient, and I would then look at the record and determine if the procedures billed for were actually recorded in the permanent record (ie if an EKG was billed, did we have the necessary documentation to back it up), or on the flip side, if I found documentation of an EKG being done, was it billed for.
Anyway, one day a patient called in and complained that someone at the facility must have disclosed her health information because her ex boyfriend knew she was pregnant, and she never told him. As with most clinics, we took this accusation extremely seriously, so the administrator ran an audit of who had accessed her file. My name came up so I was called in for a "meeting". Thankfully, my policy had always been to keep track of the records I audited. I did it by the med record #, so after digging I was able to prove that my access of said record was totally innocent.
I am sure, as an RN, you understand when I say that I could give a rat's AS* about any ones personal info. I see so much of it every day that nothing surprises me in terms of "unique". In fact I generally have absolutely no idea of a patients name, although it is there. Because I work in the abstract, and not personal care, one medical records looks like all the rest to me.
So much of our documentation was the legally required save our own butt stuff. Something like 43 pages for the RN admitting someone to the floor, for every Medicare patient, not to mention the other paperwork (dr orders, nursing assessment, RT, Dietary, personal possessions, treatment plan, X-rays, labs, meds, the whole shootin match.
Setting up TPN, irrigating a central line, restarting an IV, hanging piggybacks, changing out fluids, checking the NAs charting, fixing a blocked foley, calling for transport, documenting meals (the NAs were always busy after meals with bedpans and toileting), seeing who hadn’t had a BM for three days, checking on pain relief, giving narcotics, counting narcoticss, charting narcotics, *sheesh!* Working shortstaffed really sucked.
I’m glad I’m retired.