Kaiser Permanente has drafted a proposal to replace the current approach of using separate agreements for these items with this single approach. The purpose of this policy is to ensure that entries made in information systems meet legal and ethical requirements. Examples of health care professional entered information include the entry or updating of significant health problems, visit diagnoses and procedures, allergies, preventive health prompts, discharge summaries, consultation reports, orders, laboratory results review and receipt, and visit notes. Our patient s health care record has officially been designated to comprise both the paper chart and patient specific information in our online systems. Background All human entries in clinical information systems databases must be accurate and attributable to an individual.
Electronic signatures have the same legal meaning and significance as a hand written signature.
In the patient record, signatures are used to identify the person who made an entry, to indicate that a review of an entry has been made, and to designate approval of an entry. When one logs on to the computer system, the use of the individual s user identification code and secret password is meant to inform the computer system who is using it and keeps track of each action taken. When one enters information, the last step before the computer accepts the information is a request to press a specific key and or enter a code to confirm the entry. This is the electronic equivalent of signing on paper. The computer keeps a record of the action taken, the user identification code, the time, and the date.