Anmelden

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:

Maintain Confidentiality and Security:

  • Never share computer signatures or passwords with anyone, including colleagues or float nurses, to prevent unauthorized access to patient records.
  • Always log out of computer terminals when not in use to prevent unauthorized access to patient information.

Error Correction Procedures:

  • Adhere to the correct error correction procedure if a mistake is made in documentation.
  • To correct an error after saving it, mark it as a "mistaken entry," provide the correct information and date, and initial the correction.
  • If data is entered into the wrong chart, clearly indicate it as a "mistaken entry—wrong chart" and sign off.

Record Modification and Authority:

  • Never add, modify, or delete records without authorization or specific authority.
  • Ensure any modifications or deletions are documented appropriately and by organizational policies and procedures.

Data Backup and Recovery:

  • Maintain backup files for stored records as a precautionary measure to prevent data loss in the event of system failures or errors.
  • If a portion of the permanent record is unintentionally deleted, identify the computer file, including the date, time, and initials, and report the incident to the manager.

Patient Information Protection:

  • Avoid leaving patient information visible on computer monitors to maintain patient confidentiality.
  • Keep a log of every copy of a computerized file generated by the system to track access and ensure data integrity.

Secure Communication:

  • Do not send protected health information via unencrypted email to prevent unauthorized access or breaches of patient confidentiality. Use encrypted methods for secure communication.

By following these guidelines and strategies, healthcare professionals ensure the safe and secure utilization of computer charting systems, protect patient confidentiality, maintain data integrity, and mitigate the risks associated with electronic health record management.

Tags

Computer ChartingAmerican Nurses AssociationCanadian Nurses AssociationPatient ConfidentialityData IntegrityError Correction ProceduresRecord ModificationData BackupSecure CommunicationUnauthorized AccessProtected Health InformationElectronic Health Record Management

Aus Kapitel 9:

article

Now Playing

9.15 : Guidelines and Strategies for Safe Computer Charting

Documentation and Reporting

705 Ansichten

article

9.1 : Introduction to Documentation and Reporting

Documentation and Reporting

1.3K Ansichten

article

9.2 : Purpose of Health Records I

Documentation and Reporting

1.0K Ansichten

article

9.3 : Purpose of Health Records II

Documentation and Reporting

864 Ansichten

article

9.4 : Guidelines for Nursing Documentation I

Documentation and Reporting

915 Ansichten

article

9.5 : Guidelines for Nursing Documentation II

Documentation and Reporting

920 Ansichten

article

9.6 : Types of Records I: Unit and Nurses Records

Documentation and Reporting

936 Ansichten

article

9.7 : Types of Records II: Educational and Administrative Records

Documentation and Reporting

699 Ansichten

article

9.8 : Methods of Documentation I: Source-Oriented Records

Documentation and Reporting

1.0K Ansichten

article

9.9 : Methods of Documentation II: POMR

Documentation and Reporting

818 Ansichten

article

9.10 : Methods of Documentation III: PIE

Documentation and Reporting

1.2K Ansichten

article

9.11 : Methods of Documentation IV: Focus Charting

Documentation and Reporting

907 Ansichten

article

9.12 : Methods of Documentation V: CBE

Documentation and Reporting

783 Ansichten

article

9.13 : Methods of Documentation VI: Case Management Model

Documentation and Reporting

530 Ansichten

article

9.14 : Methods of Documentation VII: EMR

Documentation and Reporting

753 Ansichten

See More

JoVE Logo

Datenschutz

Nutzungsbedingungen

Richtlinien

Forschung

Lehre

ÜBER JoVE

Copyright © 2025 MyJoVE Corporation. Alle Rechte vorbehalten