CMS SOM App. W, Tag C-1118

health care professional.

Interpretive Guidelines §485.635(a)(4)(iv)

Entries in the medical record may be made only by individuals as specified in CAH and

medical staff policies. All entries in the medical record must be timed, dated, and

authenticated, and a method established to identify the author. The identification may

include written signatures, initials, computer key, or other code.

When rubber stamps are authorized, the individual whose signature the stamp represents

shall place in the administrative offices of the CAH a signed statement to the effect that

he/she is the only one who has the stamp and uses it. There shall be no delegation to

another individual.

A list of computer or other codes and written signatures must be readily available and

maintained under adequate safeguards. There shall be sanctions for improper or

unauthorized use of stamp, computer key, or other code signatures. The CAH must have

policies and procedures in place and operational before an electronic medical record

system would be deemed acceptable.

The parts of the medical record that are the responsibility of the MD/DO must be

authenticated by this individual. When non-MD/DOs have been approved for such duties

as taking medical histories or documenting aspects of physical examination, such

information shall be appropriately authenticated by the responsible MD/DO. Any entries

in the medical record by house staff or non-MD/DOs that require counter signing by

supervisory or attending medical staff members shall be defined in the medical staff rules

and regulations.

All entries in the medical record must be authenticated.

Authentication would include at a minimum:

• The CAH has a method to establish the identity of the author of each entry. This

would include verification of the author of faxed orders/entries or computer

entries.

• The author takes a specific action to verify that the entry is his/her entry or that

he/she is responsible for the entry, that the entry is accurate.

• The timing of the entry is noted and correct.

Timing documents the time and date of each entry (orders, reports, notes etc.). Timing

establishes when an order was given, when an activity happened or when an activity is to

take place. Timing and dating entries are necessary for patient safety and quality of care.

Timing and dating of entries establishes a baseline for future actions or assessments and

establishes a timeline of events. Many patient interventions or assessments are based on

time intervals or time lines of various signs, symptoms, or events. There must be a

specific action by the author to indicate that the entry is, in fact, verified and accurate.

Failure to disapprove an entry within a specific time period is not acceptable as

authentication.

A system of auto-authentication in which a MD/DO or other practitioner authenticates a

report before transcription is not consistent with these requirements. There must be a

method of determining that the practitioner did, in fact, authenticate the document after it

was transcribed.

Survey Procedures §485.635(a)(4)(iv)

• Verify that entries are authenticated.

• Verify that the department maintains a current list of authenticated signatures,

written initials, codes, and stamps when such are used for authorship

identification.

• Verify that computer or other code signatures are authorized by the CAH’S

governing body and that a list of these codes is maintained under adequate

safeguards by the CAH administration.

• Verify that the CAH’S policies and procedures provide for appropriate sanctions

for unauthorized or improper use of the computer codes.

• Examine the CAH’S policies and procedures for using the system, and determine

if documents are being authenticated after transcription.

• For sampled records, are there dated and authenticated signatures by appropriate

MD/DOs and/or mid-level practitioners, as needed?