Certified Inpatient Coding (CIC) Practice Exam

How is the authentication of an entry in the medical record defined?

1. Accessing information on a need-to-know basis

2. Identifying oneself as the author by signing the entry

3. Verifying that patient information is correct

4. Ensuring that the entry is legible

The correct answer is: Identifying oneself as the author by signing the entry

The authentication of an entry in the medical record is defined as identifying oneself as the author by signing the entry. This process is critical in medical documentation, as it not only indicates who created the record but also ensures accountability for the information provided. By signing the entry, the author confirms the authenticity of the documented information and assumes responsibility for its accuracy and integrity. This is essential in maintaining trust and legal compliance within healthcare settings, as well as safeguarding the patient's personal health information. In contrast, accessing information on a need-to-know basis relates to privacy and data security rather than the authentication of a record. Verifying that patient information is correct pertains more to the accuracy of the data itself, not the process of validating who recorded it. Ensuring that the entry is legible is about the readability of the documentation, which supports communication but does not directly impact the identification of the author. Therefore, signing the entry is the definitive action that authenticates the record.