Can I prove my EHR documentation was deleted?

[Nurse Beth, MSN]

Sorry this happened, and it's very serious.

Deleting or altering a nurse's documentation in an electronic medical record (EMR) can be illegal and is unethical, as it may constitute tampering with medical records.

The specifics can vary by jurisdiction and institution, but deleting or altering documentation violates laws and regulations requiring accurate and complete medical records. This could lead to legal consequences, including penalties or loss of licensure for individuals involved in the tampering.

Proving Documentation Was Deleted

• Audit logs. EHR systems typically have audit logs that track all actions taken within the system, including who accessed, added, modified, or deleted entries. These logs can serve as evidence that documentation was deleted.
• Provide the date of documentation and deletion.
• Screenshots/printouts. If you suspect your documentation might be altered, take screenshots or print out your documentation immediately after entering it.
• Witnesses. Colleagues who have seen the original documentation can also serve as witnesses.

Notification

• Supervisor/manager. Inform your immediate supervisor or manager about the deletion. They are responsible for ensuring the integrity of the medical records and can initiate an internal investigation.
• IT Department. Notify the IT department or the EMR system administrator, as they can access audit logs and investigate who made the deletions.
• Compliance officer. Many healthcare institutions have a compliance officer who oversees adherence to laws and regulations. Reporting to them ensures that the issue is handled according to institutional policies.
• Legal counsel. If you believe the deletion could have legal ramifications, consult with your institution's legal department or seek external legal advice.

Taking prompt action and documenting your concerns thoroughly can help address and rectify the situation effectively.

Best wishes,

Nurse Beth