Legal Questions
Penny Simpson Brooke JD, MS, APRN

February 2011 
Volume 41  Number 2
Pages 14 - 15
  PDF Version Available!

My patient's daughter is a nurse who wants to review her mother's medical record. Can she do that without permission?-D.R., ILL.No. Several years ago a nurse who looked at her mother's medical record without the mother's written permission was charged with a violation of the Health Insurance Portability and Accountability Act. So make sure you know the law and your facility's policy and procedure.Even if your patient has been legally determined to be incompetent, the daughter needs formal authority to review the record, such as power of attorney or evidence that she's the designated surrogate decision maker. If the designated surrogate is someone else in the family, this person could authorize the daughter to review her mother's medical record. If the facility's policy is to allow family members of unconscious or incompetent patients to review the medical record, the facility must honor its policy. But it's important that all family members agree with whatever decision is reached so no one later complains about the daughter gaining unauthorized access to this private information.I had trouble performing venipuncture on a patient who's abused I.V. drugs for many years. We have no I.V. team, so after two unsuccessful tries, I followed hospital policy and procedure and asked a more experienced colleague to step in. In the meantime, my patient became angry and said, "Just let me do it-I know what I'm doing!!"Fortunately my colleague was able to establish venous access, but it made me wonder-why not let him perform venipuncture, given that he's probably very skillful?-K.H., MASS.Allowing a patient to establish his own venous access would be extremely risky for you and the facility. If the patient injured himself, the decision would be impossible to defend in court.All you need to tell a patient is that it's against hospital policy to let patients perform invasive procedures. If the patient continues to insist, bring your manager and the patient's healthcare provider into

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