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§482.24(c)(1) -- All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. All entries in the medical record must be legible.
Authentication of medical record entries may include written signatures, initials, computer key, or other code. For authentication, in written or electronic form, a method must be established to identify the author.
Medical records found in hospitals are systematic documentation of patient's medical care and history. They contain a patient's health information (which is also referred to as PHI) that includes health history, billing information, identification information, and findings of medical examinations.
The privacy protection of medical records normally dictates that your medical records are confidential, and Nevada law limits access to medical records to the patient or the patient's representative or investigator.
Entries are typically authenticated by a signature. At a minimum the signature should include the first initial, last name and title/credential.
I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested (e.g., medical-history form you filled out; physician and nurses' notes; test results; consultations with specialists; referrals).]
Authentication. confirms the content and accuracy of the entry into the medical record by written signature, initials, or computer-generated signature code.
compliant HIPAA release form must, at the very least, contain the following information: A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed.