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Discussion

Is changing a computer chart wrong?

I am a new OR nurse before the OR I worked on a Renal Med/Surg floor. May of this year, the OR began a computer charting system. The charting is being audited by a employee without a nursing background. she is making changes to our charts and then printing a corrected copy without consulting with the nurse who entered the original chart documentation. The nurse manager is aware of these changes being made. The corrected copies are then being placed in the patient's chart. I and other nurses in the OR feel this can't be legal. If this was a written chart being audited the nurse who did the charting would make the correction not a person who wasn't even involved witht the patient's care. Some input on the subject would be greatly appreicated.

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I agree with you. Charting should be done by only those who have provided the care. I'm sure this person means to save drama and bring the chart up to par, but it not right.

I would definately contact your Risk Manager, if you have one, about this practice.

  • Admin

In the computer system we use, there's a spot to document if making a late entry and then we're supposed to say why. We have other people checking the documentation, and then changes that need to be made are forwarded to us. The nurse who finished the case is responsible for making the necessary changes.

We had late entry spots, and if the person wasn't there for a while to change an entry...that was documented and an approximate date of correction as well as the nurse managers signature in case questions were asked.

IN the late entry point, all implementations and assessment data pertaining to the correction were added to show that it was addressed and how.

Once the person that made the error came in, they had to do a written explanation and computerized late entry. The written explanation was kept with managment, the computerized was in the chart. That way if something were to occur down the line, then it was well documented in managment and in chart.

  • Guides

Waaaayyyyyyyy back when, when the idea of computer charting first came up, I objected because I wanted my notes to be in my handwriting - for the very reason that no one else could change what I wrote, without making it obvious.

There is no way this person should be changing anything you charted! :angryfire :angryfire :angryfire

Considering most court cases are several years after the fact, how can you defend your actions if there is a possiblity someone changed the chart?! Lawyers would have a field day! "You say you did this, but my client says you never did! Did you have someone put it in later to cover your "donkey"? Do you really remember everything you did in detail on every patient you ever saw? On the other hand, my client only has to remember her own case, you have to remember hundreds. Who should we believe remembers best?" blah blah blah.:deadhorse

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