Who is the only person who can authenticate the information in a patient’s medical record?
a. the attending physician
b. the attending nurse
c. the medical facility that’s caring for the patient
d. the person who creates the data in the record

D. the person who creates the data in the record

Explanation: Authentication is the confirmation of the content of an entry in a medical record. It acts as verification of the accuracy of the information. An entry could be authenticated with a signature, an initial, or with a computer-generated code.

Physical entry of the data may be delegated.

Authentication, on the other hand, must be performed by the person who creates the data. This requirement is logically required by the very notion of authentication—that is, only the person who created the information can truly verify it. For example, a physician may dictate the details of a patient’s history, physical examination, and medical decision making into a handheld dictation device. The physician’s voice recording is later retrieved by a medical transcriptionist, who types the dictation into the form of a medical report. The medical coder retrieves information from the typed medical report and assigns codes to it. These codes determine the amount that the insurance company will pay the physician for the services provided to the patient...PF

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