Informatics, Documentation & Confidentiality in the Digital Chart

Accurate, timely documentation in the electronic health record (EHR) is a legal record of care — the standard is to chart objectively (what was observed/done), promptly, and without alteration; a late entry should be clearly labeled as such rather than inserted as if it were written in real time. Never share login credentials, and always log out of a workstation before stepping away — leaving a session open under your credentials makes you responsible for anything entered under your name.