Protect Your Practice: The Power of Signed Records
At the end of a long day of back-to-back patients, completing and signing your health care record entries can feel like the last hurdle between you and going home. It is tempting to leave a health care record entry open, planning to finish or sign it later.
But that small step matters more than it seems.
For all health care practitioners, timely and signed patient health care records are a foundation of professional practice. They support patient safety, enable effective collaboration, and provide critical protection to health care practitioners in regulatory or legal contexts. Completing documentation and promptly signing health care record entries is a consistent habit that helps ensure health care records remain a true reflection of the care provided.
Timely record keeping, occurring as soon as possible after treatment is provided, supports accurate recall of the patient visit and reduces the risk of omissions or errors. When health care record entries are completed long after the care is provided, the health care record entries may be viewed as less reliable. In regulatory and legal settings, it is often assumed that undocumented care did not occur, and late entries may appear to lack objectivity.
Signing and dating health care record entries confirm that the information has been reviewed and verified by the treating health care practitioner. Unsigned entries may be interpreted as incomplete and will likely carry less clinical and legal authority. In most electronic health record systems, drafts are automatically saved while you work and marked with indicators such as Unsaved Changes or Changes Saved. However, when a health care record entry remains open and unsigned, additional notes added later are not always timestamped or tracked until the health care record is signed. Promptly signing health care records ensures a clear, reliable clinical timeline and preserves the integrity of the health care record.
Health care records are a key tool for communication with other health care providers. Patients may receive care from multiple health care practitioners concurrently or within a short time frame. When collaboration between health care practitioners occurs, complete and signed health care record entries support the sharing of current patient health information, treatment plan and response to treatment ensuring accurate information is shared in the best interest of the patient.
Maintaining timely, accurate, and signed health care records are important to support safe, ethical, and effective patient care. They are also an essential record of the treating health care practitioner’s clinical judgement, the care provided, and patient’s response to treatment.
For record keeping requirements, see:
Traditional Chinese medicine practitioners and acupuncturists
