Question: What does the term authentication refer to in medical documentation?

(o-then″ti-kā′shŏn) In an electronic health record or other computer system, a security mechanism (such as a digital signature) that provides for a unique means of identifying a system user.

What is authentication of medical records?

Authentication is an attestation that something, such as a medical record, is genuine. The purpose of authentication is to show authorship and assign responsibility for an act, event, condition, opinion, or diagnosis. Every entry in the health record should be authenticated and traceable to the author of the entry.

Who can authenticate entries in medical records?

Authentication of Entries and Methods of Authentication

Every entry in the medical record must be authenticated by the author – an entry should not be made or signed by someone other than the author. This includes all types of entries such as narrative/progress notes, assessments, flowsheets, orders, etc.

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Which of the following is an acceptable means of authenticating a record entry?

Which of the following is an acceptable means of authenticating a record entry? The physician personally signs the entry. What is the primary purpose of the history and physical examination?

What is considered medical documentation?

Typically, medical documentation consists of operative notes, progress notes, physician orders, physician certification, physical therapy notes, ER records, or other notes and/or written documents; it may include ECG/EKG, tracings, images, X-rays, videotapes and other media. …

How do you authenticate medical records at a trial?

To summarize, first, as to records: The records have to be authenticated by offering evidence that they were prepared by agents of the medical facility in the ordinary course of business at or near the time of the relevant act, condition or event contained in the records, and that the mode of preparation indicate the …

How is authentication represented in an electronic health record?

How is authentication represented in an electronic health record? By electronic signature. … It applies to the electronic health record in the context of submission of a computer printout as evidence in court of patient care.

Who is responsible for documenting information in the medical record?

Providers are responsible for documenting each patient encounter completely, accurately, and on time.

What are the documentation standards for completion of records?

All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials. 4. All entries are dated.

Why is documentation in the medical record such an important part of preparing the patient for a physical examination?

IM 7.2 The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. … The physician should document how the patient is improved.

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What are the five C’s in medical record documentation?

Client’s Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality.

What type of information should be documented in medical health records?

Medical records should include the following information:

  • Patient identification.
  • Information relevant to diagnosis or treatment.
  • Treatment plan.
  • Medication and dosage levels.
  • Information and advice given, consent discussions.

What are the documentation standards?

Documentation process standards define the process used to produce documents (example here). This means that you set out the procedures involved in document development and the software tools used for document production. … Document process quality standards must be flexible and able to cope with all types of documents.

What are the different types of documentation?

The four kinds of documentation are:

  • learning-oriented tutorials.
  • goal-oriented how-to guides.
  • understanding-oriented discussions.
  • information-oriented reference material.