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Electronic signature patient medical record

So what does it really mean to sign my notes in my EMR? I'm Erin Jackson with Jackson LLP Healthcare Lawyers. This question really comes down to the difference between digital signatures, locked documents, and electronic signatures. Now, an electronic signature is most commonly the type where you either type in your name and it gets glued onto a document or you can sometimes upload a photo of your signature, like if you're signing documents to close on a house, or you're signing documents through Adobe. These are ways to electronically sign a document and frequently it has something that looks somewhat like your signature. One type of electronic signature is a digital signature. A digital signature is a type of cryptographic operation whereby you bind your signature to the data. It uses what's called a PKI, or public key infrastructure, in order to connect your identity with the data in question. Now, once you digitally sign something, it's locked for further editing. If you've ever entered a digital signature using Adobe's function to do this, there's other software systems as well that offer it. If you've ever issued your digital signature this way, it will frequently tell you that once you've done this, the document is locked for editing. What this means when it's locked for editing is there's no more filling out fields, there's no more editing it, there's no more adding annotations, and there's no more adding additional signatures to it. In fact, if you do make edits to a document after it has been digitally signed, you void the signature on that document. Is it okay to just lock your notes or do you need to sign them? This is a common question among healthcare providers, and one that is addressed by many EMRs. Many EMR systems, after a patient encounter, allow you to enter data and then, after a period of inactivity, they automatically lock the notes. This means that if you go back later to add additional information, it won't allow you to do so without noting that the document has been edited after the fact. So, some providers have chosen to fill in the information from the patient encounter and then essentially go on to something else, or exit out of the program, and using the locked document function in lieu of a signature. However, providers really should be documenting the patient visit immediately afterwards or contemporaneously, then signing it, and then locking it. This ensures that a patient encounter note is documented, signed by the treating provider, and then locked for further editing. So there's several awesome benefits of digital signatures. Because the law on this is somewhat complicated, I'm going to include a link to our blog posts on electronic signatures here and you can check out all the details as required by the ESIGN Act to learn more. However, there are some great ways to use and reasons to use electronic signatures in your healthcare practice. One, they have long term retention. Two, the PKI standard is a really high one. Three, the digital footprint is a really clear one. And four, they're generally accepted in the industry now and particularly useful now that everyone's using EMRs. We'd love to hear your questions and we'd love for you to follow our channel. You can subscribe below and you can also learn more at