SECTION 310:667-19-10. Signature

(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.

[Source: Added at 12 Ok Reg 1555, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 20 Ok Reg 1664, eff 6-12-03; Amended at 21 Ok Reg 2785, eff 7-12-04]