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Tip: Learn common EHR entry authentication terms

EHR Connection, October 29, 2007

EHR entry authentication is necessary to ensure that your records are legally sound, says Debra Kohn, MPH, RHIA, FACHE, CPIHMS, principal of Dak Systems Consulting in San Mateo, CA.

Authentication, a process that ensures users are who they claim to be, prevents unauthorized users from accessing data or using another's identity to sign documents.

Some important terms include:

Document lockdown refers to a closed document that the author may not alter after applying an e-signature. This method preserves the integrity of the authenticated document because an addendum is necessary if the clinician has made an error.

Date and time stamping shows the chronology of events. Entries must include a complete date-month, day, year, time zone, and indication as to whether your organization records military time.

Audit trails are usage control reports that provide information concerning every transaction and activity in the system. They indicate who signed a document, as well as when, where and how. They also can reveal unauthorized attempts to access information.

Multiple e-signatures are necessary so that your system maintains and recognizes all authors who contribute to an entry or note. Your system should not overwrite multiple contributors and identify only the final author of an entry.

This tip was brought to you by the October issue of Electronic Health Records Briefing.

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