Medical/Clinical Record - Authentication Document
Can a single document be used to authenticate all unsigned orders, notes, and other entries in a medical/clinical record?
Any examples are for illustrative purposes only.
Yes but only under limited circumstances.
The process for the use of a single document must include a list of the specific items to be authenticated, with an opportunity for the practitioner to authenticate each entry on the document if they so choose.
A single statement signed by the practitioner indicating that all unsigned notes, orders and other entries are hereby authenticated without a listing of every item covered, would not meet the requirements of this standard.
The use of such a 'global' authentication process is guided by medical/clinical record organizational policies and procedures.
Yes but only under limited circumstances.
The process for the use of a single document must include a list of the specific items to be authenticated, with an opportunity for the practitioner to authenticate each entry on the document if they so choose.
A single statement signed by the practitioner indicating that all unsigned notes, orders and other entries are hereby authenticated without a listing of every item covered, would not meet the requirements of this standard.
The use of such a 'global' authentication process is guided by medical/clinical record organizational policies and procedures.
Last updated on May 19, 2020
Manual:
Behavioral Health
Chapter:
Record of Care Treatment and Services RC