— 照護管理 · MEDIUM · MCQ —
護理師在電子病歷中發現錯誤，下列何者為正確做法？
A nurse identifies an error in the electronic medical record. Which action is correct?
- AAsk a colleague to fix the error請同事修正錯誤
- BDraw a single line through the error在錯誤處劃一條單線
- CDelete the incorrect entry immediately立即刪除不正確的條目
- DFollow facility policy for amending electronic records✓ 正解遵循機構關於修改電子紀錄的政策
— Explanation · 中文詳解 —
電子病歷（Electronic Medical Record, EMR）的正確修正方式必須嚴格遵守醫療機構的政策（Facility Policy）。EMR 系統具備完整的稽核軌跡（Audit Trail），記錄每一筆修改的時間、人員與內容。若直接刪除會掩蓋原始錯誤資訊，違反醫療法律責任與病歷完整性原則。
The correct way to amend an entry in the electronic medical record (EMR) is to strictly follow the healthcare facility's policy. EMR systems maintain a complete audit trail that records the time, individual, and content of every modification. Deleting an entry outright would obscure the original information, violating both legal accountability and the principle of record integrity.
✦ 台美臨床差異
台灣醫院多數依據評鑑標準規範電子病歷修正，與美國相似，均禁止刪除紀錄。但在美國醫院，重點更在於「Audit Trail」的透明度，若發現錯誤，依據各院系統設計，通常是輸入「Corrected Entry」來註記，而非單純修改內容。