Medical Records and the Law

Authorship and Countersignatures 61diagnosis, prescription of treatment, or any other act defined by applicablestate law to be the practice of medicine, these entries should becountersigned by a licensed physician, who may be an attending or aresident physician. In most states, it is a violation of the medical licensureact for anyone to practice medicine without a license unless the individualis practicing under the direct, proximate supervision of aphysician licensed to practice in that state.Therefore, without evidenceof such supervision, the student or unlicensed resident might be held tohave violated state law.The rules governing a physician’s countersignatureof medical records entries made by other authorized personnelshould be set forth in the hospital’s medical staff rules and regulations.Similarly, the entries of undergraduate nursing students should becountersigned by a licensed professional nurse, if such entries documentthe practice of professional nursing as defined by the state’s nursinglicensure act. Without evidence of proper supervision, a nursingstudent practicing professional nursing could be held in violation of thestate’s nursing licensure act unless the act specifically authorizes nursingstudents to practice nursing in the course of their studies toward aregistered nursing degree. 25 The nursing licensure acts of some statesalso authorize graduate nurses who have applied for a license to practiceprofessional nursing for a limited time without a license. 26 Graduate,unlicensed nurses in those states may make entries in medicalrecords without countersignature by a licensed nurse. In states thathave no specific allowances for practice by such graduates, however,their entries should be countersigned.In many hospitals, social workers participate in the care of patientsand request that they be allowed to make entries in their patients’charts. Generally, there is no prohibition against such entries as long asthe information placed in the record is relevant to the patient’s treatment.Entries by social service staff members should be limited to relevantfactual observations or to data and judgments that such staffmembers are competent to make. Highly subjective remarks, if essentialto the record, must be worded carefully and must be clearly relevantto the patient’s care. Social workers should be discouraged from keepingrecords of their observations and judgments other than those includedin the medical record.25See, e.g., 225 Ill. Comp. Stat. Ann. 65/5-15.26Ibid.