Medical Records and the Law

64 CHAPTER 4: MEDICAL RECORDS ENTRIESresponsible for ordering, providing, or evaluating the service furnished.38 The author of each entry must be identified and must authenticatethe entry. Under those regulations, authentication mayinclude signatures, written initials, or computer entry.States also permit authentication by rubber stamp or computer key,in addition to the traditional handwritten signature. All of the statesthat permit this type of authentication impose controls to safeguardagainst abuse. The controls ensure that only properly authorized individualshave access to, and use of, the authenticating devices. For example,in California, the State Department of Health Services hasregulations providing the following:Medical records shall be completed promptly and authenticatedor signed by a physician, dentist or podiatrist within two weeksfollowing the patient’s discharge. Medical records may be authenticatedby a signature stamp or computer key, in lieu of aphysician’s signature, only when that physician has placed asigned statement in the hospital administrative offices to the effectthat he is the only person who:(1) has possession of the stamp or key(2) will use the stamp or key 39Similarly, Arkansas permits physicians to use rubber-stamp signaturesif the method is approved in writing by the hospital administrator andthe medical records committee, and requires that the stamp be lockedin the medical records department when the physician is not using it. 40Indiana requires that all physicians’ orders for medication and treatmentbe in writing or acceptable computerized form, and be signed byhand or acceptable computerized form in accordance with hospital andmedical staff policies. All verbal orders must be authenticated by thephysician and documented in the medical record within 48 hours. 41The Centers for Medicare & Medicaid Services (CMS), the agencywithin the DHHS principally responsible for the administration of theMedicare and Medicaid programs, warns that the use of alternative3842 C.F.R. § 482.24(c)(1).39Cal. Code Regs. tit. 22, § 70751(g).40Ark. Code 14(B)(8).41Ind. Admin. Code tit. 410, r. 15-1-5(b)(3)(N) and 15-1-5(b)(3)(O).