Allow Signed Professional Medical History For Free

Authentication is an attestation that something, such as a medical record, is genuine.

In terms of healthcare authentication, CEs must ensure that a person is actually who he or she claims to be before they are given access to ePHI. Essentially, individuals need to be able to prove their identity in order to gain access to sensitive information.

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.

These include: Adverse event documentation. Doctor's orders. Behavioral health notes. Lab results.

The signature for each entry must be legible and should include the practitioner's first and last name. For clarification purposes, we recommend you include your applicable credentials (e.g., P.A., D.O. or M.D.).

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.

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.

The purpose of a physician's signature in a medical record or operative report is to clearly identify who ordered and provided supplies or services for the patient. It also serves as a testament that the services he or she provided were accurately and fully documented, reviewed, and authenticated.