9.15 : 安全电子病历记录的指南和策略

In the digital healthcare era, nurses must follow the guidelines and strategies for secure computer charting to ensure patient safety and accurate documentation.

Nurses must never share passwords or computer signatures with anyone, including the float nurse or unit doctor.

Once signed in, it is crucial to supervise the computer continuously to safeguard the patient's confidential data from potential breaches.

In error-filled entries, label the entry as "mistaken entry- wrong chart," followed by the correct information, including the date and signature.

Health records are subject to modification, addition, or deletion only by authorized nurses per the hospital's policies.

To address any accidental deletion of a section in the permanent record, nurses should provide a written explanation, including the reason, date, time, and initials. Additionally, it is crucial to justify the incident to the manager.

As a precautionary measure, nurses should ensure that all stored records have a backup.

Additionally, a log should be maintained to track duplicate computerized files generated from the system.

Nurses should encrypt emails whenever they share protected health information.