Q: When documenting care in the electronic medical record that someone else has provided, what is the responsibility of the person providing the care in documenting that he/she actually provided the care that someone else documented he/she did? Cosign? Progress note?
A: Linda Harrington, rn, phd, cns, cphq, cenp, cphims, Lynn Choromanski, rn-bc, msn, Nancy Biddle, rn, msn, and Kimberly Acosta, rn, bsn, reply:
To answer this question, we will provide a few definitions and case examples with screen shots, and we will discuss applicable law, standards, and guidelines. The answer is in part dependent upon hospital policy and the design of the electronic health record (EHR) being used.
The following definitions are important to understand when answering this question.
Authorship: attributing the origination of specific EHR...