Computer charting

[UM Review RN, ASN, RN]

For those of you who are using computer charting, someone told me that all charts, even historical ones, are modifiable. That is, it's possible to delete someone's chart information (at least in one section) on a prior admission. Once deleted, there is no "restore" function and it's not possible to get that info back.

Which means:

Polly Patient sees Dr. X on 6/10/08. She's admitted for something-itis, treated, and released. A year later, she goes back for a surgery.

Is it possible to delete the first chart, I mean lose it completely, and never be able to get it back?

Is there no backup?

This concerns me because of hackers and because of the mistakes that people are capable of making.

Anyone have any info on this?

[Envy]

It depends on what your hospital has. Normally, the information should go from your computer to a server, then to a storage disk and then to a backup storage disk. These are all in different buildings and frequently in different towns.

[Altra, BSN, RN]

While losing data is possible, systems are generally in place to prevent such a disaster.

Yes, electronic medical records are modifiable, but a modified entry is identified as having been modified on such-and-such date. Paper medical records can also be retrieved from storage & modified, or lost for that matter.

Edited to add: in the electronic systems I've worked with, entries can be modified by the original person who made the entry within 48 hours of the original entry, although it is clear that the entry was created at DateX,TimeY and modified on DateY,TimeX. No one can modify or delete another person's entry, and after 48 hours you can't even delete or modify your own.

[rags]

I don't know so much about deleting old charts information from prior admissions but I do know that in our system we use, it is possible to delete things that cannot be recovered. For example:

Under the intervention charting you can change the status mode of each intervention and one of the choices is to cancel it. If you cancel an intervention that has been charted on all the charting goes with it and cannot be undone.

Generally we cannot pull up old admissions when a pt comes in without many warnings popping up saying that this pt has been discharged. So, getting into the wrong charting for them and accidently removing any of it would have to be done intentionally I would think. I also believe that at our hospital once a pt has been discharged, medical records pulls all the information from our system and files it elsewhere under that pt's permanent records. The information is still in the program we use for our reference but medical records will bring up the pt's old charts on a repeat admission.

rags

[megananne7]

I don't know about losing the entire electronic chart, but as for modifying data, only the person that entered the information and delete any assessment/vitals/i&o information and can only be modified up to 24 hr after it was first entered.

[LovingNurse, BSN, RN]

Where I work, any previous encounters in the system (anything other than the current admission) are "view only" and cannot be modified. All are backed up.

:behindpc: