who is authorized to make documentations in the medical record

Asked on by mamma12

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jraineharrison | College Teacher | (Level 2) Assistant Educator

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Personnel can access and document in the medical record on a need to know basis.  That is, the individual must be directly involved in the patient's care.  Those involved in patient's care may include clinical and non-clinical personnel.  

Clinical personnel who may document in medical records include physicians, nurses, nurse practitioners, physical therapists, occupational therapists, pharmacists, social workers, and chaplains.

Non-clinical personnel may also document in medical records.  Non-clinical personnel may include volunteers, administrative staff, medical transcriptionists, and students who have an authorized signer. Each of these individuals may only document in the medical records if they can demonstrate that they have a reason to be viewing the patient's record. 


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