Allow Countersign Patient Medical Record For Free

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.).

They should include: 1) All relevant clinical findings. 2) A record of the decisions made and actions agreed as well as the identity of who made the decisions and agreed the actions. 3) A record of the information given to patients. 4) A record of any drugs prescribed or other investigations or treatments performed.

Handwritten Signatures We consider a signature valid if it's handwritten and legible. If your signature isn't legible, the reviewer must confirm it by comparing your signature to a log or attestation statement. A printed signature below the illegible signature in the original record is acceptable.

§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.

Medical records: Organize these into subfolders by department or specialization, then by provider. Include all doctor's notes, visit summaries, lab results and any imaging or specialized tests (with CDs and results included) ordered by that doctor.

Ideally, all entries in the medical record should be made in black ink. This would make it simple to produce a photoreproduction and ensure that the subsequent copies would 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.

Anyone documenting in the medical record should be credentialed and/or have the authority and right to document as defined by facility policy. Individuals must be trained and competent in the fundamental documentation practices of the facility and legal documentation standards.