The person who records information in a patient record bears direct responsibility for the accuracy, relevance, and appropriateness of that information. This responsibility attaches to the individual making the entry, not only to the organization.
Each person entering data into a patient record must ensure that:
- the information recorded is accurate and essential for the care relationship
- entries are made and signed under their own identity
- they are not made on behalf of others without authorization
- they can account for any entry they have made if required
The organisation should also define the specific circumstances under which a patient journal entry may be left unsigned. This includes clarifying the situations where signing is deemed unnecessary. A procedure must be in place to document the reason for the missing signature and ensure the entry's integrity and accountability are maintained.
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