Medical Records and the Law

68 CHAPTER 4: MEDICAL RECORDS ENTRIEStreatment. A physician’s signature on the medical record gives evidencethat the practitioner actually reviewed the record and acknowledged thatit represented a complete and accurate record of the patient’s course oftreatment. Although a signature does not prove conclusively that thephysician reviewed the record, it is stronger evidence of such verificationthan a signature on a separate form authorizing authentication of therecord.Although the introduction of computer technology has enabledhospitals to introduce new methods for facilitating a physician’s role inthe authentication process, healthcare institutions should not lose sightof their responsibility in creating accurate and complete medicalrecords. Any computer system that does not require physicians to reviewreports after they have been transcribed is likely to fall short ofboth federal and state authentication standards, as well as to create seriousliability risks for the facility implementing such a system. (For amore detailed discussion of EHRs, see Chapter 13.)Verbal OrdersIn the course of providing patient care, healthcare practitioners oftendeliver orders verbally. Because of the effect that this practice may haveon the quality of patient care, it is important for healthcare facilities toestablish standards governing how these orders are received andrecorded. Healthcare facilities should require physicians to deliver theirorders in writing or by computer entry, except in situations in whichverbal orders are unavoidable. Written and computer entry orders arepreferable to verbal ones because written and computer entry orderscreate fewer chances for error.Hospital licensing regulations in most states require all physician ordersto be written in the patient’s medical record and authenticated. 50Indiana requires that (a) all verbal orders be repeated and verified, (b)that the repetition and verification be documented in the patient’smedical record, (c) that the record be signed by the professional whotook the order, and (d) that if no repetition and verification occurred,the ordering physician must then authenticate and date the verbalorder within 48 hours. 51 Other state licensure laws extend the time pe-50See, e.g., S.C. Code Ann. Regs. r. 61-16 § 601.6.51Ind. Admin. Code tit. 410, r. 15-1.5-5(b)(3)(O).