— 降低風險 · EASY · MCQ —
護理師發現電子健康紀錄 (EHR) 中有一項輸入錯誤。護理師應採取什麼行動？
A nurse identifies an error in the electronic health record (EHR) of a client. Which action should the nurse take?
- ADo nothing as the error is minor不做任何處理，因為錯誤很小
- BDelete the entry and rewrite it correctly刪除該筆記錄並重新正確輸入
- CDocument an amendment to correct the error✓ 正解記錄修正附註以更正錯誤
- DUse correction fluid to cover the error使用修正液覆蓋錯誤
— Explanation · 中文詳解 —
電子健康紀錄系統設計上應保有原始紀錄。若發現錯誤，不應刪除或遮蓋（這會被視為竄改證據），而是應依據機構政策，透過「修正附註」（Addendum）功能進行修正，並註明日期、時間與錯誤原因，確保紀錄的完整性與可追溯性。
Electronic health records are designed to preserve the original entry. If an error is identified, it should not be deleted or obscured (as this is considered tampering with evidence); instead, the correction should be made through an addendum function in accordance with institutional policy, with the date, time, and reason for the correction documented to ensure the integrity and traceability of the record.
✦ 台美臨床差異
台灣目前醫院多數已電子化，病歷更正流程嚴格遵照醫院資訊規範，不可擅自刪除。