How Andre Approaches Signing Your Notes in Eaglesoft
This document is not intended to provide legal advice. Although I have gone to great lengths to make sure the information is accurate and useful, I recommend you consult a lawyer if you are seeking legal advice. In no event will the creator of this document be liable for loss of profits or special, indirect, or consequential damages. No action relating to obligations here under may be brought by the reader or author more than one year after the occurrence of the event giving rise to any cause of action. The information and suggestions contained in the structure of this document have been developed from sources believed to be reliable. However, the writer accepts no legal responsibility for the correctness and completeness of this material and its application to specific factual situations.
Many Eaglesoft users have asked me: How do we “sign” our Progress Notes?
Eaglesoft is your Electronic Health Record (EHR) system. You have the ability to sign your Progress Notes (PN) electronically and the PNs are automatically dated and time stamped based on the Windows clock (at the workstation level or Server level depending on the domain configuration and proper Eaglesoft Login/Logoff processes.
One of the most important guidelines for using an Electronic Signature (e-signatures) is that the Practice Management Software must include protections against modification as well as administrative safeguards that correspond to standards and laws.
Interestingly, there is no single overwhelmingly accepted standard, law, or regulation for dental practices. There are many individual resources to review existing language specific to e-signatures, attestation, and authorship of medical record documents in an EHR. Unfortunately, these sources may contradict one another, making it even more difficult for the organization to determine its policy.
In Eaglesoft as an EHR, authentication is the Security Profile setup. This process verifies a user’s identity and grants the individual access to areas of Eaglesoft. Authentication is important because it assigns responsibility to the user for entries he or she creates, modifies, or views.
According to the ADA:
Attorneys and doctors debate who should make the entries in the dental record, but state law will determine this in most cases. Keep in mind that the dentist is ultimately responsible for the patient’s chart.
Some entries may be delegated to office staff if allowed by state law. The administrative assistant can record telephone calls; prescription changes; and canceled, changed, and failed appointments. The dental assistant records the patient’s comments, concerns and disposition; vital signs; medical history notations; radiographs and other diagnostic tools taken and used; and instructions given to the patient, etc. Dentists add clinical impressions, treatments performed and any pertinent information. All entries should be initialed and/or signed by the team member writing the entry and the dentist.
If the dentist opts not to make his or her own entries, he/she should dictate what to write to the assistant. The dentist should review the contents of the entry as soon as possible for accuracy and then sign or initial it.
The term electronic signature is frequently used in references and regulations in reference to signatures in a digital format. However, an electronic signature is a generic, technology-neutral term for the various ways that an electronic record can be signed (attested). It can include a digitized image of a signature, a biometric identifier, a secret code or PIN, or a digital signature. Manually entering the provider’s license number (similar to typing a Pin) can be a great verification tool to indicate that Notes have been reviewed. In California, for example, it was suggested that a Progress Notes entry should include the dentist’s name, followed by License number. The name can be electronically entered (as part of a pre-written template) but the license number should be manually entered. The Provider who takes radiographs, should also input their name and corresponding license number. If documentation of care is recorded by an assistant for the dentist when both are present, such as in a scribe role, the Note should include identifying information of both individuals. Identity should be clearly noted respectively (e.g., scribe versus caregiver).
In Electronic Health Records, authentication is the security process of verifying a user’s identity that authorizes the individual to access the system (e.g., the sign-on Username and Password combination process). Authentication is important because it assigns responsibility to the user for entries he or she creates, modifies, or views. Attestation, on the other hand, is the act of applying an e-signature to the content, showing authorship and legal responsibility for a particular unit of information.
Example:
Electronically signed by Dentist: __________ / License # __________
What are the Signature Requirements for Medical Records?
• Acceptable methods for handwritten signatures are:
1. A legible full signature
2. A legible first initial and last name
3. An illegible signature accompanied by signature log or attestation statement
4. Initials over a printed or typed name
5. Electronic signature
• Unacceptable signature methods are as follows:
1. Rubber stamp signatures, except for clinical diagnostic tests when a treating physician who authenticates medical documentation by handwritten or electronic signature, indicates that he or she intended the clinical diagnostic test be performed
2. Illegible signatures with no additional documentation to identify the signature
3. Initials with no additional documentation identifying them
4. An unsigned note
5. A note with the statement “signature on file”
The sign-in for your software is unique to the user and manually adding a License Number adds a layer of personal authorization. Some providers use assistants to enter notes into the system for subsequent authorization. Your Practice must put checks and balances in place to ensure that the legally responsible individual has reviewed the health record entries and authenticated them. It is suggested that the Practice assign scribes unique user IDs to identify them as the authors of the entries and require the authorized providers or physicians to attest to the accuracy of the entries. This can be the Username/Password sign in from the Assistant and then the doctor’s attestation.
This information is found in CREWED Progress Notes. My book containing Templates for all Dental Progress Notes. Available here.
DISCLAIMER:
This is a resource guide and all decisions on each dental office setup should remain the sole decision of the dentist/owner of the practice. Eaglesoft is a registered trademark of Patterson Dental Company. All other software or products mentioned are the property of their respective owners. Although Andre Shirdan was an employee of Patterson Dental, he is not associated with Eaglesoft or Patterson Dental Company or endorsed by Patterson or any other Company Mentioned in this blog
