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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