Epic Charting

I'd be very surprised if your epic allows someone to completely delete some documentation without leaving a clearly visible audit trail. I can't even delete my own charting without that. Perhaps you documented under the wrong patient?

We recently had charting not show up and the nurse swore she did it.We called our charting hotline and indeed they found it was charted but could not explain why it had showed up. So it can happen.

I was terminated once for "insufficient documentation", the home health company claimed that I went days without charting anything. And being fired for that, in Indiana, they don't have to pay unemployment benefits. I hired an attorney that had someone that specialized in electronic documentation. They found that the nursing director had deleted all of my charting. I got benefits, was given a cash settlement from that company, and was offered my job back (turned it down, who wants to work for a company like that?), director was fired. There are times now that I have charted, watched it save and went to look up something later and poof its gone, although corporate IT can find it, cannot explain why I can't see it. Electronics are generally traceable, but nothing is foolproof

In our version of EPIC, if you admimistered the med I could come back and edit your administration, but it would be obvious in the MAR (ie: now the administration would be charted under my name). If you charted a urine output I could change it and there would be a black triangle showing the entry was modified and again, my name would be on the cell. I'm sure there's a way to pull the audit trail for both examples.

As many have said, it varies with each version, but where I work you can alter, but it is very obvious.

Silly_Sally_RN said:

Our version of EPIC allows you to alter other's charting, but it leaves an audit trail that is clearly visible. There would be a red triangle in the upper right corner of the cell. If I clicked in that box, I could see what was charted, when, and by whom, and when, what and who changed the charting. The IT department/computer people should also be able to track who was in the chart.

When I teach EPIC to the new hires, I tell them the only reason they should ever change someone else's charting would be an obvious error and they aren't around to correct it themselves. My example is when my CNA mixed up the HR and RR. I called the aide to confirm and then changed it. I specifically tell them that if they try to alter someone's charting for the purpose of getting another person in trouble, it won't work.

Yes. I agree with that. When I was trained on EPIC, I was told that any alterations can be tracked.

Yes, it's possible to delete charting but it's still trackable by IT.

I worked as a Database Applications administrator for several years. It was Oracle financials and other modules, not EPIC or any EMR's. I could be way off base but I would think it's close to the same process on the Database side. My first thought was that the charting could be removed on the database side using a roll back option, meaning the OP's co-worker may have a friend in IT. As far as auditing trails, it should be picked up but that's not always 100% unless they are looking at the database logs at the time of the transaction. I saw other posters mention that after saving charting, it disappears but IT can see the record. I would hazard a guess that there is a job running that is picking up the transactions on the front end for posting/ application EMR side and it hasn't been saved on the database side. Once the job runs, it should have been saved. Although, if the job ended it error for any reason, it would not have been saved. My thoughts would be to ask the EPIC database admin to pull the logs for that day to be reviewed along with an audit to that field where the charting was to check for updates. My 2 cents for what it's worth.