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TJC

Entries in the medical record are authenticated.

TJC RC.11.02.01

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TJC RC.11.02.01

TJC RC.11.02.01

Entries in the medical record are authenticated.

(1)

All orders, including verbal orders, are dated, timed, and authenticated by the ordering physician or other licensed practitioner who is responsible for the patient's care and who is authorized to write orders, in accordance with hospital policy, law and regulation, and medical staff bylaws, rules, and regulations.

(2)

The hospital uses a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.