forensic issues of computerized medical records

There is a strong trend to computerization of medical records. This method of recording information about a patient offers many advantages.

• Access to a medical record may be electronically limited. For example, a nursing assistant may be permitted to only enter vital signs but not review orders, laboratory results, or write nursing notes. A paper medical record may be viewed by anyone.

It is possible to determine who has accessed an electronic chart. For example, Registered Nurse Charles Cullen, who confessed to killing many patients, was finally caught in 2003 through the use of computers. His excessive use of digoxin, a medication used to kill his victims, was preceded by accessing medical records of patients to whom he was not assigned. The digoxin was stored in a computerized drug dispensing cart, which recorded his removal of the drug.

• Tampering with the medical record is much more difficult to do with an electronic system. Software typically permits the healthcare professional to correct errors in typing and phrasing immediately after the error is made. Software programs contain a feature that makes the entry unalterable after a certain time or event. Typically, the entry is made unchangeable once it is authenticated. There is also a regularly scheduled backup time to store data, making it impossible for someone to delete previous entries once they are saved. If a correction (such as an incorrect entry, misspelled word, or typographical error) is to be made after an entry is saved or authenticated, the software program should contain a way to accomplish this task. This is often achieved in the same way it is done in paper systems, by bracketing the mistaken entry, adding the correct information, and giving a reason for the change, such as “ the wrong chart.”

A clock embedded in the software program indicates the precise time and date of an entry, and in this way, it becomes impossible to backdate information to make it look as if it was entered earlier. Each entry in the electronic medical record carries a time and date stamp, as well as the identity of the user.

• With sufficient safeguards in place, an electronic record is more reliable and less likely to be lost.

See Part 2 for more thoughts on the forensic issues associated with electronic medical records.

From Nursing Documentation, in Nursing Malpractice, Fourth Edition

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