Which is an example of acceptable authentication of a medical record entry

Signature logs or attestation statements are two acceptable methods to authenticate a record. This excludes orders and Certificates of Medical Necessity (CMNs).

What are the characteristics of an acceptable medical record?

All documentation in the medical record should be accurate and adequate pertinent to the health care experiences of the patient including telephone conversation or verbal orders. All entries made must be related to health problems and treatment of the patient only.

What are three 3 elements of documentation in the client's medical record?

Authentication is an attestation that something, such as a medical record, is genuine. The purpose of authentication is to show authorship and assign responsibility for an act, event, condition, opinion, or diagnosis. Every entry in the health record should be authenticated and traceable to the author of the entry.

Is the confirmation of the content of an entry in a medical record?

Today, the SOAP note – an acronym for Subjective, Objective, Assessment, and Plan – is the most common method of documentation used by providers to input notes into patients' medical records. They allow providers to record and share information in a universal, systematic and easy-to-read format.