Paper to Computer Charting

Specialties Operating Room

Published

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. :eek:

Specializes in Operating Room.

The system that we use allows the circulating nurse that relieves you to "edit" your documentation as far as most of the screens go. However, we have one section of the chart called "notes" and once you've posted a note, you can't take it back.

Before we take the patient to PACU, we have to close out the chart. So, at least someone can't go in after the fact 2 or 3 days later to change something.

We pretty much leave the charting as is when we relieve someone unless the person is new and didn't do a proper job of it or to add something.

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Specializes in Operating Room.

I couldn't edit my other post...

When we relieve someone, most of us tend to add stuff and not delete something someone else wrote under "comments" ,for example. I suppose someone could delete something just to be a jerk if they didn't like you, but their name would show up on the chart too, so if you get nailed for improper charting, they'll get in trouble also.I always make sure to exit out of the chart when being relieved so that other persons name is on the chart as well.

We've had our system for a while and no legal problems that I've heard of.

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Specializes in OR.
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.

I will definitely do this. The McKesson rep is on site sometimes, and I plan on asking her.

Thanks again.

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Specializes in OR.
I couldn't edit my other post...

When we relieve someone, most of us tend to add stuff and not delete something someone else wrote under "comments" ,for example. I suppose someone could delete something just to be a jerk if they didn't like you, but their name would show up on the chart too, so if you get nailed for improper charting, they'll get in trouble also.I always make sure to exit out of the chart when being relieved so that other persons name is on the chart as well.

We've had our system for a while and no legal problems that I've heard of.

I am glad you haven't had any legal problems. Do you use orsos? I still think it is dangerous to have someone able to delete/change your charting. I would rather have keystrokes identified per user and not allow anyone to change someone else's charting (no matter what the reason). It is definitely a good idea to log off before stepping away from the computer. Thanks.

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I am glad you haven't had any legal problems. Do you use orsos? I still think it is dangerous to have someone able to delete/change your charting. I would rather have keystrokes identified per user and not allow anyone to change someone else's charting (no matter what the reason). It is definitely a good idea to log off before stepping away from the computer. Thanks.

ACK! ALWAYS LOG OFF WHEN YOU LEAVE YOU DESK!

Cybersecurity 101

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Would there be any way to maybe annotate your name or initials into the documentation that way you know you documented it. We do that where I work. We have McKesson as well, but the program we have shows when changes were made and by whom.

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Specializes in OR.
Would there be any way to maybe annotate your name or initials into the documentation that way you know you documented it. We do that where I work. We have McKesson as well, but the program we have shows when changes were made and by whom.

That is what I am hoping for. We go live on July 1. Hoping to speak directly to the McKesson rep before then. Thanks ;)

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