Attest to content of Record Entry (1 instance)
Attest Record Entry Content
Occurs when Record Entry content is attested for accuracy and completeness – typically during/after conclusion of an Action.- Attested Record Entry content is the responsibility of Attesting Author. The Attesting Author may be someone other than the originating Author, i.e., a supervisor, proctor, preceptor or other designated individual.- An Audit Trigger is initiated to track Record Entry attestation.The purpose of attestation is to show authorship and assign responsibility for an act, event, condition, opinion, E233 or diagnosis. Every Record Entry must be identified with the author and should not be made or signed by someone other than the author unless they have authority to do so. For example, a resident may author Record Entry content but the person taking legal authority for the content is the “attester” – both individuals should be identified. (Note: A transcriptionist may transcribe an author's notes and a senior clinician may attest to the accuracy of another's statement of events.)- Author: All users who create or contribute content and have a role in the development of a Record Entry. Some entries may be created by an author whose role is a student, transcriber or scribe. -Attester: A user who takes legal authority for Record Entry content. The attester is often the same as the author, but they may also be an individual with authority to take responsibility for Record Entry content created in whole or in part by another author(s) (e.g., student, scribe, transcriptionist).Reference: ISO 21089, Section 12.2.2.