Center for Improvement in Healthcare Quality Newsletter
March 2022

CIHQ-ARS Blog

Can you Identify Authors and Authenticators in the Medical Record During Downtime?

By: Kim McGuire
Identification of those who authored and authenticated entries into the medical record became a lot easier, and one may even say a bit taken for granted, when electronic medical records (EMR) replaced paper charting in many healthcare organizations. We sign up for access, get a log in and set a password that links everything that we look at, write and review in a medical record to our unique identifier. Simple and one thing that we do not need to worry about…right?!
Well, then the inevitable happens……the EMR has downtime, planned or unplanned!
CMS §482.24(b) states that “the hospital must have a system of author identification…. that ensures the integrity of the authentication and protects the security of all record entries”.
This CMS standard includes downtime (paper) procedures.
We all know that healthcare handwriting can often be less than desirable, or at times illegible. Does your organization have a way to identify signatures of entries when pen and paper are used? Do you have a procedure in place to ensure the integrity of authentication when downtime is in place?
This brings us back to the times where we had signatures with printed names on all our forms or a signature page in the front of the chart to identify authors. There are many methods that one can implement to meet this standard and there is no one size fits all.
Staff education also comes into the forefront with this topic as well. Staff should know the organizational expectations of downtime processes and procedures. This includes what the charting requirements are, the signature verification process, and even the correct forms to use and how to make them part of the medical record.
For leadership, this may seem like something that is just common or something that everyone knows. But that assumption can lead to confusion and even frustration on the part of staff when an unexpected downtime occurs. We must remember that not all staff have worked in healthcare when paper charting was prevalent or common and downtime procedures vary among organizations.
Here is a little insight that was shared with me by staff nurses from an organization that I visited with and discussed authentication of medical records and downtime procedures. There are procedures in place and files with downtime paperwork for staff and providers to use. It was shared that so many staff members had never really used paper charting and that there was confusion as to what to write (document) and how to do it. When documenting on paper, there was not a drop down or charting by exception as in the EMR. The gratitude there is during this time for clerks or unit secretaries is interesting. They must manually fax requests to departments for diagnostic testing and receive faxes for labs and other results that are not just uploaded into the computer system. The normal flow of the day was disturbed and what was a normal day just a few hours prior became a process of “now what” and “how is this done differently”.
As for signing, dating, and timing each entry…well it is another layer of a process that needs to be followed because there is not an enter button that automatically does that for you. Although at times tedious, there is a group effort for chart reviews and real time coaching to support staff in knowing the importance of the tasks, in the ‘not so normal’ downtime procedures.
In healthcare, we are all used to thriving in a world of change and the unexpected. Even during these times, we also get to ensure that standards are met and that we can clearly identify authors and authentications in the medical record whether in the EMR or on paper, if that is your process or if that it just your downtime.

References

Centers for Medicare and Medicaid Services, (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Retrieved from cms.gov
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