9.15:
Guidelines and Strategies for Safe Computer Charting
In the digital healthcare era, nurses must follow the guidelines and strategies for secure computer charting to ensure patient safety and accurate documentation.
Nurses must never share passwords or computer signatures with anyone, including the float nurse or unit doctor.
Once signed in, it is crucial to supervise the computer continuously to safeguard the patient's confidential data from potential breaches.
In error-filled entries, label the entry as "mistaken entry- wrong chart," followed by the correct information, including the date and signature.
Health records are subject to modification, addition, or deletion only by authorized nurses per the hospital's policies.
To address any accidental deletion of a section in the permanent record, nurses should provide a written explanation, including the reason, date, time, and initials. Additionally, it is crucial to justify the incident to the manager.
As a precautionary measure, nurses should ensure that all stored records have a backup.
Additionally, a log should be maintained to track duplicate computerized files generated from the system.
Nurses should encrypt emails whenever they share protected health information.
9.15:
Guidelines and Strategies for Safe Computer Charting
The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
- • Never share computer signatures or passwords with anyone, including colleagues or float nurses, to prevent unauthorized access to patient records.
- • Always log out of computer terminals when not in use to prevent unauthorized access to patient information.
Error Correction Procedures:
- • Adhere to the correct error correction procedure if a mistake is made in documentation.
- • To correct an error after saving it, mark it as a "mistaken entry," provide the correct information and date, and initial the correction.
- • If data is entered into the wrong chart, clearly indicate it as a "mistaken entry—wrong chart" and sign off.
Record Modification and Authority:
- • Never add, modify, or delete records without authorization or specific authority.
- • Ensure any modifications or deletions are documented appropriately and by organizational policies and procedures.
Data Backup and Recovery:
- • Maintain backup files for stored records as a precautionary measure to prevent data loss in the event of system failures or errors.
- • If a portion of the permanent record is unintentionally deleted, identify the computer file, including the date, time, and initials, and report the incident to the manager.
Patient Information Protection:
- • Avoid leaving patient information visible on computer monitors to maintain patient confidentiality.
- • Keep a log of every copy of a computerized file generated by the system to track access and ensure data integrity.
Secure Communication:
- • Do not send protected health information via unencrypted email to prevent unauthorized access or breaches of patient confidentiality. Use encrypted methods for secure communication.
By following these guidelines and strategies, healthcare professionals ensure the safe and secure utilization of computer charting systems, protect patient confidentiality, maintain data integrity, and mitigate the risks associated with electronic health record management.