COMPLETION, TIMELINESS AND AUTHENTICATION OF MEDICAL RECORDS

A.  All inpatient Medical Records must be completed within 14 days from the date of discharge (California Code of Regulations, Title 22, section 70751).  Additional requirements may also be included in the applicable UC__ hospital Medical Staff By-Laws and/or Rules and Regulations.
B.  All operative and procedure reports must be completed immediately after surgery. 
C.  All Medical Record entries are to be dated, the time entered, and signed. 
D.Certain electronic methods of authenticating the Medical Record, including methods such as passwords, access codes, or key cards may be allowed provided certain requirements are met.  The methodology for authenticating the document electronically must comply with UC__ electronic signature standards (See Section XII below: Authentication of Entries). The entries may be authenticated by a signature stamp or computer key, in lieu  of a medical staff member’s signature, only when that medical staff member has placed a signed statement with the Medical Center to the effect that the  member is the only person who:
1) has possession of the stamp or key (or sequence of keys); and
2) will use the stamp or key (or sequence of keys).  
E.  Fax signatures are acceptable.  

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