protecting info from overwriting or deletion

[daubney]

Just learning how to use this ? chat program. I am trying to evaluate telephone triage and identify concerns or potholes in general. If you were asked " why did you handle a call in this way " where is your evidence based practice information to support your practice. Other area of concern... how can nurses ensure their documentation is protected from overwriting or deletion and identify the time advice was given as opposed to when the file was closed. These`areas of concern could be critical in a legal setting.

[rninformatics, DNP, RN]

daubney,

These sounds like excellent questions to ask the vendor who created your telephone triage software. If the system does not have some link, or functionalitythat connections documented research related Evidence Based Practice then your organization should establish protocals, policies and procedures utilizing EBP for decision support. Remember its just "software" not an experienced clinician making a "nursing decision".

Hope that helps.

[daubney]

Angela,

I somehow stumbled on your reply today. I am embroiled in a professional battle that involves my electronic charts. It seems to me that their should be "footprints" to indicate if one's charts have been altered after the writer has closed the chart. I am very concerned about the ability to alter charts and strongly suspect my charts have been tampered with. No harm has come to clients yet the result of my questioning revised protocols that do not seem to be evidence based resulted in allegations of unsafe practice in regard to my practice. It is difficult to prove that one's charts have indeed been altered when the facility has control over the records. Any idea on how to approach either concern. This situation concerns me and it flags a potential problem for other nurses. The idea of contacting the vendor is a good one yet there is a conflict of interest as the vendor and the facility have financial ties. If I were the vendor I would not appreciate my product protocols being altered by an RN, and endorsed by an MD. How could this situation have been prevented? I am now skeptical of the practice of electronic charting.

[rninformatics, DNP, RN]

Hi daubney,

Most software contains an audit trail or reports that can be generated from the audit trails. An audit trail is a program specifically designed within the software that tells you which user(s) did what, documented when, deleted what, edited something, etc. Accessing the audit trail/report should give you additional info .....but here is the catch..... the debt and detail of the individual softwares' audit trails vary drastically from software vendor product to software vendor product . I've seen cases where neither the individual user nor the hospital's IS Staff could access the audit trail as it was designed only to be accessed by the Vendor's programmer. I've also see cases where the audit trail or the report(s) produced were worthless as they did not tell exactly what the user did only that he/she was in the lab section or viewed the narrative notes, etc.

Angela,

I somehow stumbled on your reply today. I am embroiled in a professional battle that involves my electronic charts. It seems to me that their should be "footprints" to indicate if one's charts have been altered after the writer has closed the chart. I am very concerned about the ability to alter charts and strongly suspect my charts have been tampered with. No harm has come to clients yet the result of my questioning revised protocols that do not seem to be evidence based resulted in allegations of unsafe practice in regard to my practice. It is difficult to prove that one's charts have indeed been altered when the facility has control over the records. Any idea on how to approach either concern. This situation concerns me and it flags a potential problem for other nurses. The idea of contacting the vendor is a good one yet there is a conflict of interest as the vendor and the facility have financial ties. If I were the vendor I would not appreciate my product protocols being altered by an RN, and endorsed by an MD. How could this situation have been prevented? I am now skeptical of the practice of electronic charting.

[daubney]

Do you have any suggestions for me? I have been out of work since Nov 2004. I am in university - took my BN last year at university of Manitoba while waiting for an arbitration that supported the facility. This is a poor show and I would not have believed it could happen but it did and it can happen again. I should begin my masters next year and plan to pursue this situation to protect others and myself.

[rninformatics, DNP, RN]

daubney,

feel free to e-mail me privately, we can exchange phone numbers and talk.

Do you have any suggestions for me? I have been out of work since Nov 2004. I am in university - took my BN last year at university of Manitoba while waiting for an arbitration that supported the facility. This is a poor show and I would not have believed it could happen but it did and it can happen again. I should begin my masters next year and plan to pursue this situation to protect others and myself.

[daubney]

Angela,

I will call as soon as I have a phone # let me know on my private e-mail the best time and best day. I have a frightening but thought provoking scenario.

[daubney]

Angela,

2004-2011....is this my life? Contact me for an update...if this hadn't happened to me I would not have believed it.