Health Information Management

Sign, date, time: The HIM director's continuing quest for compliance

HIM Connection, August 4, 2009

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Obtaining physicians’ signatures on their orders usually isn’t difficult. Asking them to provide the date and time is another matter altogether. A revised Joint Commission (formerly JCAHO) standard that took effect July 1 will most likely serve as a wake-up call for many noncompliant physicians. The revised standard—RC.01.01.01, EPs 18 and 19—requires hospitals to ensure all entries in the medical record are not only signed, but also dated and timed.

The signing, dating, and timing of verbal or telephone orders is the major concern for 61% of the 91 respondents who participated in MRB’s Joint Commission benchmark survey in June. 

Editor’s note: To read more about RC.01.01.01 or to purchase a copy of this article for $10, visit the HCPro Web site. Subscribers to Medical Records Briefing can access this article in the August issue.



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