As A Healthcare Facility, It Is Critical That The Organizati

As A Healthcare Facility It Is Critical That The Organizations Polici

As a healthcare facility, it is critical that the organization’s policies be reviewed and/or rewritten to reflect changes occurring in the industry. Authentication policies can address both paper records and electronic health records, especially in hybrid systems. Detailed policies are necessary because patient record information comes from multiple sources, with numerous entries made daily by various healthcare providers. Methods to verify that record entries are authentic include adherence to medical staff bylaws, rules, regulations, and applicable state and federal laws. This policy will compare and contrast the policies from the County Health Department (Kansas) and Banner Health, evaluating them against standards from the Illinois Licensing Requirements document. The focus will be solely on authentication processes in health records. Based on the comparison, I will incorporate relevant standards and best practices to develop a comprehensive organization-wide authentication policy, limited to one page.

Paper For Above instruction

Introduction

In the evolving landscape of healthcare documentation, ensuring the authenticity of health records has become paramount. Accurate and verified health information is fundamental for patient safety, proper treatment, legal compliance, and quality assurance. As healthcare systems transition toward electronic and hybrid record systems, establishing robust authentication policies aligns with federal, state, and accreditation standards. This paper compares and contrasts two policies—the County Kansas Medical Record Policy and Banner Health’s Documentation Requirements—and evaluates them against Illinois licensing standards. The goal is to synthesize effective practices and standards into a cohesive, organization-wide authentication policy.

Comparison of Policies

The County Kansas Medical Record Policy emphasizes strict adherence to state licensing regulations, requiring healthcare providers to verify each entry with appropriate identifiers and signatures, whether handwritten or electronic. It mandates that all entries must be attributable to a specific author, with clear documentation of who made the record, when, and in what capacity. The policy underscores the importance of authentication through signatures and timestamps, aligning with state legal requirements to protect the integrity of medical records.

Conversely, Banner Health’s Documentation Requirements specify a comprehensive approach to authentication, emphasizing electronic signatures, password protection, and audit trails. It mandates that electronic entries must be validated through secure login procedures, digital signatures, and regular system audits. Banner’s policy incorporates HIPAA’s guidelines and emphasizes the importance of controlling access to prevent unauthorized record modifications. It also details procedures for correcting entries and ensuring that subsequent changes are traceable.

While both policies prioritize authenticity, the Kansas policy primarily relies on manual signatures and signatures’ legal validation, consistent with traditional record-keeping. Banner Health’s approach is more technologically advanced, leveraging digital signatures, login credentials, and audit logs to ensure record integrity within electronic systems.

Standards from the Illinois Licensing Requirements

The Illinois Licensing Standards mandate that all patient records must be authentic, complete, and properly signed or electronically validated. The standards specify that each entry must be attributable to a specific health professional and include date and time stamps. They emphasize the importance of secure access controls for electronic health records, requiring features such as password protections and audit trails, similar to Banner’s policy.

Further, Illinois standards stipulate that procedures must be established to verify the identity of individuals making entries, whether through manual signatures or electronic authentication methods, to ensure accountability. They also highlight the necessity of regular audits to detect unauthorized modifications and ensure compliance with legal standards.

Integrating Standards into a Cohesive Authentication Policy

Drawing from the comparison, an effective organization-wide authentication policy should incorporate both traditional and electronic methods to verify record entries. The policy should mandate that all entries—paper or electronic—must be attributable to a specific individual, with verifiable signatures or electronic validation that meets legal requirements. For hybrid systems, the policy should specify that electronic signatures have the same legal standing as handwritten signatures, provided they comply with HIPAA and federal standards.

To ensure accountability, the policy should require password protections, user-specific login credentials, and audit trails for all electronic entries, aligning with Banner Health’s practices and Illinois standards. Manual signatures should be used where electronic systems are unavailable, ensuring legal compliance and record integrity. Additionally, procedures for correcting errors, establishing signatures, and verifying identities must be explicitly defined and regularly audited.

Sample Organization-Wide Authentication Policy

Organization-Wide Authentication Policy for Health Records

To safeguard the integrity and authenticity of health records, the organization commits to adhering to best practices and legal standards for record authentication. All health record entries, whether in paper or electronic formats, must be attributable to a specific healthcare provider and verifiable at the point of entry.

For electronic health records, access will be secured through unique user login credentials with strong password requirements and multi-factor authentication where applicable. Digital signatures will be employed to validate the authenticity of electronic entries, and audit trails will record all modifications to ensure transparency and accountability. Regular audits will be conducted to review access logs and detect unauthorized activities.

Paper records will require handwritten signatures that include the provider’s name, professional title, date, and time of entry. When electronic signatures are used, they must comply with the federal regulations outlined in HIPAA and the Illinois Licensing Requirements, providing the same legal standing as handwritten signatures.

Any correction or addition to a record must include the original entry, the date and time of correction, and the identity of the individual making the change. Unauthorized access, fraudulent signatures, or alterations are violations of organizational policy and will be subject to disciplinary actions.

This policy aims to establish a comprehensive framework that upholds records’ authenticity, supports legal and regulatory compliance, and enhances patient safety across all service lines.

Conclusion

Ensuring the authenticity of health records is a core component of healthcare compliance and quality assurance. By integrating the best practices from existing policies and standards — including those from Kansas, Banner Health, and Illinois licensing requirements — healthcare organizations can develop a robust authentication policy. This policy supports secure, attributable, and verifiable documentation across hybrid systems, ultimately protecting patient rights, legal interests, and organizational integrity.

References

1. Joint Commission. (2021). Do Not Use List. The Joint Commission. https://www.jointcommission.org
2. Illinois Administrative Code. (2022). Part 250 Hospital Licensing Requirements. Illinois Department of Public Health. https://www.ilga.gov
3. United States Department of Health and Human Services (DHHS). (2020). HIPAA Privacy Rule and Security Standards. https://www.hhs.gov
4. Banner Health. (2022). Documentation Requirements for the Medical Record: Policy and Procedure. Banner Health Policies & Procedures Manual.
5. Kansas Department of Health and Environment. (2019). Medical Records Policy. Kansas Health Department.
6. American Health Information Management Association (AHIMA). (2018). Practice Briefs and Papers on Electronic Signatures and Authentication. AHIMA.
7. Federal Register. (2019). Security and Electronic Signature Standards. U.S. Government Publishing Office.
8. Creighton University. (2020). Patient Rights and Responsibilities Policy. Creighton Health Sciences.
9. University of Tennessee Health Science Center. (2021). Access to Protected Health Information. UTHSC Policy Manual.
10. UTMB Health. (2022). Prohibited Abbreviations and Authentication Procedures. UTMB Handbook of Operating Procedures.