Published Jun 29, 2022
Haboosh
1 Post
Hello everyone! I have a question about charting in the main operating room. It might be a silly question but I just wanted to ask. Let's say we're charting in EPIC and we go ahead and verified it. Then we move on to our next case. Are we ever allowed to go back and just double check our charting to make sure we didn't forget anything or charted something incorrectly? Any help is appreciated. Thank you
chare
4,324 Posts
I'm an inpatient, not OR nurse, but can't imagine the setting has any bearing. In the inpatient setting, it js completely acceptable to access the chart after providing care to update or correct your documentation.
JKL33
6,953 Posts
I assume you are asking in terms of HIPAA. You are pretty much always allowed to review your recent documentation for the reasons you state. Anyone who tries to tell you otherwise is incompetent.
The HIPAA police tried to investigate me for a violation for that very thing once and somehow my manager found a professional way to tell them to buzz off before I even received their notification. I never heard anything more about it. Just pure stupidity.