Re: Care plans & sig changes
Hi--be cautious of "I was
told"...what is the written policy?
IF you use your computer program for clarity, ease, and standardization, and print documents out of this program for placement into a paper (hard-copy) medical record, your Medical Records policy MUST state what your facility considers to be the LEGAL medical record, since you are using what is called a "hybrid" system.
From what you have said, your PAPER record is the LEGAL record. If this is so, don't worry about the computerized version--your corrected paper version should indicate the accurate information.
If you were using a total electronic medical record, you would not save any printed documents. The electronic record IS the medical record--and your system would allow corrections (not lock you out) at any point.
Good luck.
Nursing News