As a healthcare facility it is critical that the organization’s policies be reviewed and or rewritten to reflect changes occurring in the industry. Authentication policies can address the paper record, the electronic health record or both in the very common hybrid system. Detailed policies are required due to the variety of sources of patient record information and the large number of entries made by different healthcare providers in the patient’s record on a daily basis. There are several methods to ensure that the author of the entry in the medical record and entry itself has been validated which are: medical staff bylaws, rules, and regulation and state/federal laws.
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