Legal review: auto-authentication of medical records raises verification concerns.
In summary, federal and state laws require hospitals and practitioners to be accountable for the accuracy and completeness of medical records. The inevitable introduction of computer systems into the process of authenticating medical records evokes novel legal issues. Any computer system that does not require the review of reports after they are transcribed raises serious concerns regarding accountability for the accuracy and completeness of those documents. While federal and state laws have recognized that a signature on a document may be made by electronic or other means, regulatory and accrediting agencies restrict the auto-authentication of medical records. Systems have been proposed that would require the practitioner to see the report and would restrict the final signature authority to the practitioner after his or her review. These systems are likely to be closely scrutinized by regulatory authorities but may ultimately receive their approval. Currently, however, any system that does not require the physician to review and affix his or her signature to each document after reviewing the document creates serious risks for the health care facility implementing that system. Whether future changes in applicable laws will allow more flexibility for such systems is by no means certain.
Kadzielski
M A
MA
Weissburg and Aronson, Inc., Los Angeles, CA.
Reynolds
M B
MB
D004282:Documentation / Q000592:standards*; D016365:Liability, Legal; D008500:Medical Records Department, Hospital / Q000331:legislation & jurisprudence*; D016347:Medical Records Systems, Computerized / Q000331:legislation & jurisprudence*; D012308:Risk Management / Q000331:legislation & jurisprudence