Oklahoma Administrative Code › Title 310 - Oklahoma State Department of Health › Chapter 667 - Hospital Standards › Subchapter 19 - Medical Records Department › Section 310:667-19-10 - Signature

Current through Vol. 41, No. 20, July 1, 2024
(a) Records shall be authenticated and signed
				by a physician or licensed independent practitioner.
(b) Every physician or practitioner shall
				authenticate the entries which he or she makes except as allowed at OAC
				310:667-19-2(c)(4)
				and OAC 310:667-19-10(e).
(c) A
				single signature on the face sheet of the record shall not suffice to
				authenticate the entire record.
(d)
				Rubber stamp signatures may be used in any place in the medical record that
				requires a signature, provided signature identification can be verified.
				Authentication of reports by physicians or practitioners shall not take place
				prior to review of the final report by the physician or practitioner.
				Facilities allowing physicians and practitioners to use signature stamps to
				authenticate entries in the medical record shall have on file a signed
				statement from each such physician or practitioner that they have jurisdiction
				over the stamp. The use of signature stamps shall be approved in writing by the
				hospital administrator and medical records committee (or equivalent).
(e) Reports of history and physical
				examinations and discharge summaries may be authenticated by an authorized
				physician or practitioner other than the physician or practitioner who
				performed the examination or produced the summary when this practice is defined
				and approved in the medical staff bylaws or rules and regulations. If allowed,
				medical staff bylaws or rules and regulations must identify the physicians or
				practitioners who may authenticate another physician's or practitioner's report
				of history and physical examination or discharge summary, e.g. physician
				partners or attending physicians or practitioners, and define the circumstances
				under which this practice is allowed. The bylaws or rules and regulations must
				also specify that when a covering or attending physician or practitioner
				authenticates another physician's or practitioner's report of history and
				physical examination or discharge summary, such an authentication indicates
				that the covering or attending physician or practitioner assumes responsibility
				for his or her colleague's report or summary and verifies the document is
				complete, accurate, and final.
(f)
				Electronic or computerized signatures may be used any place in the medical
				record that requires a signature, provided signature identification can be
				verified. Computerized authorization shall be limited to a unique identifier
				(confidential code) used only by the individual making the entry.
				Authentication of reports by physicians or practitioners shall not take place
				prior to review of the final report by the physician or practitioner.
				Electronic or computerized signature shall be the full, legal name of physician
				or practitioner and include the professional title. The use of computerized or
				electronic signatures shall be approved in writing by the hospital
				administrator and medical records committee (or equivalent). Each physician or
				practitioner using an electronic or computerized signature shall sign and file
				a statement in the hospital administrator's office which states that:
(1) The physician or practitioner shall use
				an electronic or computer generated signature to authenticate his entries in
				the medical record;
(2) The
				signature shall be generated by a confidential code which only the physician or
				practitioner possesses;
(3) No
				person other that the physician or practitioner shall be permitted to use the
				signature.