Electronic Signatures in EHR – What is Really Required?

Electronic Signatures in EHR – What is Really Required?

9066179 m resized 600The term electronic signature is a rapidly evolving term, used both as a generic term encompassing a variety of ways that an electronic record can be signed (attested) as well as a specific type of method.

Depending on the software in use, E-signatures can be entered in many ways, such as:

  • Clicking on an “I agree” button
  • Writing one’s actual signature on an electronic tablet (like you do in the supermarket) that is attached to an electronic document
  • Simply entering a secret code or PIN when entering documentation

Standards and definitions vary across states and organizations and there is no one accepted set of regulations governing electronic signatures.

Depending on individual agency requirements, policies and software may be simple or complex.

However, there is a basic understanding of the three main purposes of an electronic signature as defined by the American Health Information Management Association (AHMIA).

These are:

  • Intent

An electronic signature signifies an approval of terms, confirmation that the signer either reviewed/approved the document or authored the document and approved the content

  • Identity

An electronic signature identifies the person signing

  • Integrity

A signature protects the document from repudiation (the signer later claiming that the entry was invalid) or alteration

Available at: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_045551.hcsp?dDocName=bok1_045551

691846 m resized 600Using a unique login (username and secret password or PIN) to enter documentation in an electronic health record is the simplest form of electronic signature.

Electronic health record (EHR) software using this method should allow the user to lock their entry from editing by others, as well as be able to generate a data trail of who entered or changed any data in a record (including retaining the original information in some way).

This brings up an important warning to all EHR users – never, ever share your unique login credentials (username and password) with others – if assigned your credentials by others when first using an EHR software program, it is suggested that you then change your password or PIN to one that only you know.

Other agencies may choose to utilize a more complex form of electronic signatures, including making pen tablets available to obtain a physical signature and capture it in the electronic record (a digitized signature) to complex forms of encryption that allow for sole usage by a provider.

Consult with your records experts in your own agency, as well local, county, and state officials to determine what is best for you and your program.

By | 2017-08-10T12:22:00+00:00 March 6th, 2012|Blog Expert|0 Comments

About the Author:

Leave A Comment