Q: Do the standards specify the time frame for authentication of documentation?
A: The Joint Commission standards do not specify the time frame for authentication of documentation. The organization is free to determine the time frame for completion of authentication. The timeframe must comply with any applicable laws or regulations. If the organization is silent on the issue for specific types of documentation, the time frame defaults to the time frame that the organization adheres to for completion of the medical record.
For example, the standard RC.01.02.01.in the AMCAH, CAMH, CAMLTC, and CAMBHC while requiring the organization to establish a time frame for completion of the medical record, specifically limits the time frame to no more than 30 days.
For example, the standard RC.01.02.01. in the AMCAH, CAMH, and CAMLTC, CAMBHC while requiring the organization to establish a time frame for completion of the medical record, specifically limits the time frame to no more than 30 days.
Q: Must signatures and dates on documentation such as verbal orders, histories and physicals, consultations, and discharged summaries, also include the time of the signature and dating?
A: If the required timeframe defined by the organization specifies a signature within a specified number of hours, then the signature and date must include the time of the signature and dating to ensure compliance.