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A record or document may be deficient because it is missing vital documents such as an operative report or discharge instructions, it is missing vital information or it contains incorrect information.
Authentication of medical record entries may include written signatures, initials, computer key, or other code. For authentication, in written or electronic form, a method must be established to identify the author.
Medical records found in hospitals are systematic documentation of patient's medical care and history. They contain a patient's health information (which is also referred to as PHI) that includes health history, billing information, identification information, and findings of medical examinations.
§482.24(c)(1) -- All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. All entries in the medical record must be legible.
To summarize, first, as to records: The records have to be authenticated by offering evidence that they were prepared by agents of the medical facility in the ordinary course of business at or near the time of the relevant act, condition or event contained in the records, and that the mode of preparation indicate the ...