For each report of care rendered to a patient, the health record entry should include the date plus the provider’s name and
For each report of care rendered to a patient, the health record entry should include the date plus the provider’s name and
For each report of care rendered to a patient, the health record entry should include the date plus the provider’s name and discipline. This ensures clarity regarding the specialized field or profession of the provider, which is crucial for accurate documentation and future reference.
All health record signatures should be identified by a minimum of name and discipline, other types of authentication other than Signature(such as written initials or computer entry)must be uniquely identified example: J.SMITH, PT
Initials can be used on certain forms in the health record like flowsheets, treatment or medication, but they can never be used narrative notes, or assessments.Initials should never be used where a signature is required by law. The physicians do put there names, so they don't initial.If a facility chooses to use initials ,they have to have full identification of the initials on the same form, I hope this helps.
Why is the "initials" (Answer C) incorrect for this question?