Signature and Dates

What Works: Effective Practices for Office-based CareComponents of the Medical Record
Signatures and Dates

Recommendation: Providers sign and date all medical record entries.

Source: CRICO/RMF Office Practice Handbook



 Effective Practice
Authenticated electronic signature
Benefits:
  • Easy to read
  • Automated signature
In practice at: HVMA (all sites), CHA (most sites), MAH Office of Dr. Christopher Peckins, Bruce Becker


 Effective Practice
Standardized forms with name and date sections that are consistently filled in.
Benefits:
  • Promotes easy identification of patient information
  • Automated dating



 Effective Practice
Providers sign their notes, review and sign their transcription.
Benefit: Providers make sure that medical record entries are correct
Common practice


View more from What Works: Effective Practices for Office-based Care