Home Care of Southern Ohio Clinical Record Guidelines
Title: Authentication by Electronic Signature
PURPOSE: To permit the use of computer-generated electronic signatures and to ensure appropriately authenticated and dated electronic signatures via secured-computer entry. Electronic signature is intended to verify authorship and has the same legal effect as a handwritten signature or initials.
Standard: Patient heath care records generated in the Clinical Link automated documentation system are authenticated through use of a unique identifier and password of the primary author who has reviewed and approved the entry. The documents specifically effected as follows:
• SN, OT, PT, ST, and SW Daily Visit Notes
• Verbal Orders
RESPONSIBLE STAFF MEMBERS: Staff of Home Care of Southern Ohio with access to Clinical Link and the right to make entries in the clinical record as defined in the HCSO Structure Standards Manual, Governing Rules, Medical Records Management (Chapter X).
(1) Entries in the automated clinical record are made only by the individual using his/her username/operator number, unique password, and computer.
(2) Authentication of the electronic signature via a computer secure entry using a unique identifier composed of a username/operator number and password.
(3) The username/operator number is assigned by the Computer Operations Specialist.
(4) The password is chosen by the employee and is not divulged to anyone. If the employee, at any time believes that the security of his/her password has been jeopardized, the employee will immediately notify the Computer Operations Specialist for a new password and will assign a new Computer Access Confidentiality Agreement. The Computer Operations Specialist will assign a new password in the system.
(5) If, at any time, the employee allows his/her password to be used by another person, corrective action will be taken, up to and including dismissal.
(6) Prior to saving a clinical document, the employee reviews the note. Upon completion of the save command, the note is locked and cannot be altered.
• Changes or corrections to the note may be added to the addendum of the note.
• Verbal Orders are locked at the time of communication with the server and cannot be altered. Any changes, revisions, or corrections to the order must be made on a separate Verbal Order.
(7) The Electronic Signature is the name, employee number, and date at the bottom of the note.
(8) Each employee shall sign a Computer Access Confidentiality Agreement upon receiving his/her computer and at least annually thereafter. Computer Access Confidentiality Agreements are maintained in locked storage by the Computer Operations Specialist.
(9) Each employee will assure that the computer is at the "Clinical Link On Screen" before walking away from his/her computer.
Source: Home Care of Southern Ohio, Portsmouth, OH.