Health Information Management

Topic: Understand common EHR entry authentication terms

HIM-HIPAA Insider, November 6, 2007

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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. 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. Some important terms related to authentication include the following:

  • 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: 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: Help maintain and recognize all authors who contribute to an entry or note. Your system should not overwrite multiple contributors, and it should only identify the final author of an entry.

Editor's note: This topic was adapted from the October issue of Electronic Health Records Briefing. For more information, click here.

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