Paper to Computer Charting

[inspir8tion]

We are going paperless. When being trained on the new computer system we were told that another nurse (giving us relief, break or lunch) that is also charting on our patient can erase or change our documentation, however, there is no trace of the change. So, if another nurse decides your documentation was not correct or that they would document it better or simply erase it, there is nothing that says that nurse did that.

My question; is that normal?

I can see being called into court in 5 years and if it wasn't documented, it wasn't done, right? So what would be my recourse!?

Should this be alarming to me and my co-workers?

Thanks.

[SuesquatchRN, BSN, RN]

That's utterly bizarre and I doubt its veracity.

I work in informatics and everything in a chart leaves an audit trail, nor can anything be changed once entered.

From whom did you hear this?

[inspir8tion]

That's utterly bizarre and I doubt its veracity.

I work in informatics and everything in a chart leaves an audit trail, nor can anything be changed once entered.

From whom did you hear this?

Our informatics person who is in charge of changing us over from paper to computer. I thought it was bizarre too. She said "it is the same exact thing as it is now". I said "no, it is not, if someone crosses out our charting now, it is still there crossed out to be seen." She insisted it was the same and I kept saying this sounds like it could but us in legal jeopardy. This was during a class and basically she told me we had to move on and it was the same as it is now; completely discounting my questions and concerns.

Most of the people I work with are just having their first foray into computers by way of our perioperative charting, so they really do not understand the implications or how computers work. I know with legal software and such, all changes are tracked and never disappear. With this system we are being taught, it would be easy for whoever is taking over the pt/charting for the room to erase or redocument what has already been written without a trace.

BTW, with our incident reports... they go through administration; who can change anything without our knowledge before sending it on to DHS, etc.

[*ac*]

I was told a lot of things in my computer training class (by non-nurses) that turned out to be incorrect.

[inspir8tion]

Also...

It will show who accessed the chart and "at some point the chart will be locked; to be determined at another time". Per the informatics nurse.

[SuesquatchRN, BSN, RN]

So it DOES show who did what.

I would honestly let it go for now. I can tell you, as the informatics nurse in my facility, that she has probably had only minimal training on the new system and is, frankly, blowing smoke up your butts because she isn't sure. What she's telling you makes no sense from a nursing, systems, or legal perspective. And your CIO would be in a heap of doo-doo should this thing work as she says it does, as would your risk management and QA people. And your counsel.

Just let it alone and learn to use the system.

For now.

:)

[inspir8tion]

Well, no, it only shows who accessed the chart. It does not show who did what (see my earlier posts).

I hope you are right that she does not know what she is talking about, but, humor me here, what if what she says is true? Who would I speak to about it?

[SuesquatchRN, BSN, RN]

Well, no, it only shows who accessed the chart. It does not show who did what (see my earlier posts).

I hope you are right that she does not know what she is talking about, but, humor me here, what if what she says is true? Who would I speak to about it?

Seriously, no one. If this is the decision that was made it's been signed off on by the board, a substantial investment has been made, and you will be shouting against the wind.

But I will guarantee that her information is incorrect. Records in a health care file are so legally protected that I can't imagine anyone buying a package that allows this.

Do you know the name of the system you're using?

[SuesquatchRN, BSN, RN]

http://www.ophthalmologyweb.com/News.aspx?spid=911&newsid=225018&headerid=911

[inspir8tion]

Yes. They have bought a system that is sunsetting called ORSOS. Perviously owned by per se and bought out by McKesson.

I appreciate your advice.

[SuesquatchRN, BSN, RN]

There is NO WAY that a McKesson product doesn't preserve every record exactly as entered with a record of who, what, when, where and why.

Honest.

Stop worrying.

McKesson is one of the giants. They would not expose themselves to the liability to which a system such as the one you describe would expose them.

[SuesquatchRN, BSN, RN]

Hey, my boss had a great idea. Call McKesson and ask.

http://www.mckesson.com/en_us/McKesson.com/For%2BHealthcare%2BProviders/Hospitals/Services%2Band%2BSupport/Services%2Band%2BSupport.html

She also doesn't think that it is possible that the system as your trainer describes.