Published Dec 1, 2017
TexasRN89
13 Posts
When I chart something in a patient's EMR and then go back and click the option to unchart due to an error, will the Uncharted response stay in the patient's medical record? Or will it be erased and show nothing... Like it never happened? Like when the patient gets discharged and their EMR is finalized and closed.
KatieMI, BSN, MSN, RN
1 Article; 2,675 Posts
It is a question to your IT department, but in majority of EMR programs such event would be marked as "was changed by (user) (date time)". Usually only the last checked option is saved and archived, so after all it is known who and when changed it but not why and what was charted first. The latter thing sometimes be recovered as well but it would take quite drastic measures.
In short: if you can use this option, it is OK to do so.
klone, MSN, RN
14,856 Posts
It absolutely does not go away. There are digital footprints, and often you can find the original comments if IT were to dig far enough. At the very least, it will show that documentation was changed, when, and by whom.
Davey Do
10,608 Posts
Makes me long for the old days when we made a mistake, we just erased our pencil marks or used White Out on our enrties in ink.
Orion81RN
962 Posts
I work private duty and the mom was watching Judge Mathis. We do paper charting, and I was charting that the plan was for the pt to return to school Monday (after being sick.) Instead, with Judge Mathis in my ear, I charted she was returning to jail. All I could do was put one line through it. I wish I could unchart that.
caliotter3
38,333 Posts
You should have been able to add a reference to Judge Mathis or someone reading this might think you were making a Freudian slip!