A. Electronic signatures must meet standards for:
1. Data integrity to protect data from accidental or unauthorized change (for example “locking” of the entry so that once signed no further untracked changes can be made to the entry);
2. Authentication to validate the correctness of the information and confirm the identity of the signer (for example requiring signer to authenticate with password or other mechanism);
3. Non-repudiation to prevent the signer from denying that he or she signed the document (for example, public/private key architecture).
At a minimum, the electronic signature must include the full name and either the credentials of the author or a unique identifier, and the date and time signed.*
B. Electronic signatures must be affixed only by that individual whose name is being affixed to the document and no other individual.
C. Countersignatures or dual signatures must meet the same requirements, and are used as required by State law and Medical Staff Rules and Regulations.
D. Initials may be used to authenticate entries on flow sheets or medication records, and the document must include a key to identify the individuals whose initials appear on the document.
E. Rubber stamp signatures: Refer to Section VI (D).
F. Documents with multiple sections or completed by multiple individuals should include a signature area on the document for all applicable staff to sign and date. Staffs who have completed sections of a form should either indicate the sections they completed at the signature line or initial the sections they completed.
G. No individual shall share electronic signature keys with any other individual.
H. Macros & Checklists. Pre-printed forms, checklists, patient questionnaires, and word-processing macros can be used to supplement written or dictated notes. When using an electronic medical record, it is acceptable for the teaching physician to use a macro as the required personal documentation, if the teaching physician adds it personally in a secured (password protected) system. In addition to the teaching physician’s macro, either the resident or the teaching physician must provide customized, patient specific information that is sufficient to support a medical necessity determination. The note in the record must sufficiently describe the specific services furnished to the specific patient on the specific date. It is insufficient documentation if both the resident and the teaching physician use macros which do not contain patient specific information. Medical record macros and checklists may be used to supplement provider written or dictated notes.
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