9.15
Directrices y estrategias para crear gráficos informáticos seguros
Las pautas y estrategias proporcionadas por la Asociación Estadounidense de Enfermeras (ANA), la Asociación Estadounidense de Registros Médicos y la A…
En la era de la atención médica digital, las enfermeras deben seguir las pautas y estrategias para la creación segura de registros informáticos para garantizar la seguridad del paciente y la documentación precisa.
Las enfermeras nunca deben compartir contraseñas o firmas de computadora con nadie, incluida la enfermera flotante o el médico de la unidad.
Una vez iniciada la sesión, es crucial supervisar el ordenador de forma continua para salvaguardar los datos confidenciales del paciente de posibles infracciones.
En las entradas completadas con errores, etiquete la entrada como "entrada errónea: gráfico incorrecto", seguido de la información correcta, incluida la fecha y la firma.
Los registros de salud están sujetos a modificación, adición o eliminación solo por parte de enfermeras autorizadas según las políticas del hospital.
Para abordar cualquier eliminación accidental de una sección en el registro permanente, las enfermeras deben proporcionar una explicación por escrito, que incluya el motivo, la fecha, la hora y las iniciales. Además, es crucial justificar el incidente ante el gerente.
Como medida de precaución, las enfermeras deben asegurarse de que todos los registros almacenados tengan una copia de seguridad.
Además, se debe mantener un registro para rastrear los archivos computarizados duplicados generados por el sistema.
Las enfermeras deben cifrar los correos electrónicos cada vez que compartan información de salud protegida.
View the full transcript and gain access to JoVE Core videos
Q1: Why should nurses never share computer passwords or signatures?
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.
Q2: What is the correct procedure for correcting a charting error in the computer system?
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.
Q3: What should a nurse do if patient data is accidentally deleted from the permanent record?
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.
Q4: How should nurses handle protected health information when communicating electronically?
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.
Q5: What precautions should nurses take to prevent unauthorized access to patient records at the computer terminal?
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.
Q6: Why is maintaining a log of computerized file copies important in healthcare charting?
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.
Q7: What authorization is required before modifying or deleting patient health records?
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.