Question

Ms. Smith analyzes patient records for deficiencies and determines that there are entries that have been authenticated using initials. She needs to identify the author of these entries to clarify information. She should reference the ____ to determine the full name of the author of the entries.

Answer 1

Ms. Smith should reference the signature log or authentication list to identify the full name of the entry's author. This is important for maintaining thorough and accountable patient records.

Step-by-step explanation:

Ms. Smith needs to reference the signature log or authentication list to determine the full name of the author of the entries that were authenticated using initials. This document is often used in healthcare settings to correlate initials and signatures to the identities of healthcare providers. It is essential for maintaining accurate patient records and ensuring proper accountability and traceability of entries within patients' medical records.

For a comprehensive understanding, Ms. Smith can also consult the facility's policy on medical record documentation, which typically includes guidelines for attributing entries to specific individuals. Additionally, if electronic health records are employed, the system usually has an audit trail feature that can be used to identify the individual associated with each entry. The information in the signature log would also be in accordance with documentation standards set by health information management practices and legal requirements.