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The physician I work for wants me to sign his electronic health records office notes. I told him that I cannot legally do this. Am I right?

Wednesday April 10, 2013
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Question:

Dear Nancy,

I work in an orthopedic office and the physician I work for wants me to sign his electronic health records office notes. This would involve using the computer while he is logged in. I told him that I cannot legally do this, but he says there is no problem. I just want to be sure that I am right about this, in case he insists.

Madison



Nancy Brent replies:

Dear Madison,

The request of the physician is not acceptable and you are right in telling him that you cannot do what he asks. One of the basic principles of documentation in any medical record, whether done in longhand or by computer, is that the person who makes the entry in the record is accountable and responsible for signing it. This is called authentication of the entry. If one does sign something for another person, the signature must be designated as such. For example, signing the doctor's name, following it with a slash and then signing your name would be legally acceptable. Since you are using an EMR, the computer program would probably require you to use your computer code or some other method, such as a password, in a way that mimics the acceptable longhand approach.

Should you participate in the request by the physician, you face at a minimum, disciplinary action by the state board of nursing if this conduct is reported. Falsification of any record kept in the course of your practice, as a professional nurse, including patient care records, is grounds for the board to take action. Also of concern is the whole issue of reimbursement, especially if insurance is involved. If you are signing his notes with his name and code, this is fraudulent.

Such conduct also is ethically unacceptable as it compromises your integrity, both as a person and as a nurse (see Provision 5 in the American Nurse's Association Code of Ethics for Nurses With Interpretive Statements, 2001). Telling the physician it is unacceptable, legally, is a good first step apparently he thinks the practice is all right and may not tolerate your refusal.

Because this is a situation taking place in a physician's office, as opposed to a hospital setting where you would have clear guidelines and resources to take advantage of, you may want to consult with a nurse attorney or attorney in your state who can provide you with specific information that can be used to sway the physician's position on this issue. The attorney also can advise you of whether or not his conduct should be reported to an outside agency (e.g., the medical board, Medicare or Medicaid, if applicable).

It may be, however, that he will not alter his approach to you signing his name in the EMR. If that is the case, your decision will be a simple one whether or not to stay in the position.

Cordially,
Nancy




Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.