or some other appropriate authorized activity. This applies regardless of the format in which the records are maintained or stored, i. e., on paper or electronically.
C.
D.
E.
Required Elements. For every patient treated as an inpatient, a medical record will contain information to justify admission and continued Hospitalization, support the diagnosis, and describe the patient’ s progress and response to medication and services. Required elements of the medical record are noted in the Hospital HIM policy on medical records.
Responsibility and Timeliness. The attending Member is responsible for the timely preparation and completion of the patient’ s medical record. All medical record entries must be authenticated, based on the stipulated timelines for each document type in these rules and regulations.
Documentation Rules. Except as otherwise stated in these Rules, Members shall comply with the documentation requirements contained herein as follows:
1. Legible. All entries in the medical record must be legible.
2. Authenticated. a.
b.
Signature. A Member or other practitioner authorized to make an entry in the medical record of a patient must sign the entry either in writing or electronically, and provide his or her printed name and discipline.
Signing Records. Members participating in legal entities in the community who desire to have the privilege of co-signing on records of all patients in whose care they participate with other Members of the same legal entity may do so only after notifying the Hospital in writing. All Members of the legal entity who will participate in co-signing records to authenticate patient treatment will be required to sign the request. These letters shall state that those Members of the entity participating in co-signing of records share equal rights and responsibilities to their patients.
3. Medical Students. Student entries must include the identification of the student’ s status and be counter-signed by the supervising Member within twenty-four( 24) hours. Student documentation may be utilized for coding and billing purposes. The overseeing provider is required to review the documentation and provide an appropriate attestation statement detailing their participation in the services rendered and provide clarification and correction to the student’ s documentation as needed.
4. Advanced Practice Providers( APPs). APPs when practicing within their scope of practice and acting under the supervision of a member of the
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