Joint Commission Standard on Electronic Signatures
Here is the standard from the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, which pertains to electronic signatures:
Standard IM.7.8
Every medical record entry is dated, its author identified, and when necessary, authenticated.
Intent of IM.7.8
The hospital has a system in place to:
- ensure that only authorized individuals make entries into medical records;
- identify the date and author of every entry in the medical record;
- enable the author to authenticate an entry to verify it is complete, accurate, and fast.
The author authenticates those entries required by hospital policy. The hospitals ensure that, at a minimum, entries of histories and physical examinations, operative procedures, consultations, and discharge summaries are authenticated. Other entries are authenticated as specified by the hospital policy or medical staff bylaws or as required by state or federal law and regulation.
Hospitals establish policies and mechanisms to ensure that only an author can authenticate his or her own entry. Indications of authentication can include written signatures or initials, rubber stamps, or computer "signatures" (or sequence of keys). The medical staff rules and regulations or policies define what entries, if any, by house staff or nonphysicians must be countersigned by supervising physicians.
Source: 1999 Hospital Accreditation Standards.
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