Printable Version of Policy
Approved: October 13, 2009
Authorship: Authenticity of Authorship in the Electronic Medical Record (EMR)
PURPOSE: The purpose of this policy is to define authorship and establish parameters to assure the highest level of authorship consistency when creating electronic notes, note sections, and/or entering discrete data with that of the EMR audit trail. Providers and/or provider support staff documenting in the EMR must avoid indiscriminately creating notes and/or entering discrete data under any other author other than themselves.
1. Authorship is the origination of recorded information. This is an action attributed to a specific individual or entity, acting at a particular time. 1
Each person should take reasonable steps to keep PHI secure from unauthorized individuals. For example:
- Workstations should not be left unattended and/or unprotected in public areas.
- Users should log out of any system or workstation when they have finished using it.
Each person should report all security breaches or violations through one of the following channels (in order of preference):
- Individual’s supervisor
- Supervisor’s supervisor
- Privacy Liaison of the Business Unit
- Privacy Office
- Compliance Hotline (anonymous)
- Education and workflows related to creating electronic notes, note sections, and/or entering discrete data should encourage users to sign after each session and/or entry of data is completed.
- AHIMA e-HIM Work Group on Maintaining the Legal EHR. “Update: Maintaining a Legally Sound Health Record—Paper and Electronic.” Journal of AHIMA 76, no. 10 (2005): 64A–L.