安全电子病历记录的指南和策略

Sharing passwords or computer signatures compromises patient record security and allows unauthorized access to confidential health information. Each nurse must maintain individual login credentials to ensure accountability and prevent unauthorized modifications to patient data. This protects patient privacy and maintains the integrity of electronic health records.

When an error is discovered, label the entry as 'mistaken entry' or 'mistaken entry—wrong chart' if data was entered into the wrong patient's record. Provide the correct information, include the date, and sign the correction. This approach maintains a clear audit trail while preserving the original entry for legal and safety documentation purposes.

Provide a written explanation documenting the reason for deletion, the date, time, and your initials. Report the incident to the manager immediately. Maintain backup files as a precautionary measure to prevent data loss. This documentation ensures accountability and helps recover information if needed for patient care or legal review.

Always encrypt emails before sending protected health information to prevent unauthorized access or breaches of patient confidentiality. Unencrypted email transmission exposes sensitive patient data to security risks. Encryption ensures that only authorized recipients can access patient information during electronic communication.

Supervise the computer continuously while logged in and never leave patient information visible on monitors. Log out when stepping away from the terminal to prevent unauthorized access to confidential data. Maintaining constant vigilance protects patient privacy and ensures that only authorized personnel view sensitive health information.

A log tracking duplicate computerized files generated by the system ensures data integrity and accountability. This record helps identify who accessed or copied patient information and when, supporting compliance with organizational policies. Maintaining detailed logs protects patient confidentiality and provides documentation for audits or investigations.

Only authorized nurses per hospital policies can modify, add, or delete health records. Any changes must be documented appropriately according to organizational procedures and legal guidelines. Unauthorized modifications compromise patient safety and violate healthcare regulations, making proper authorization essential for maintaining record integrity and legal compliance.