Addendum: new documentation added to an original entry. Addendums should be timely and bear the current date and reason for the additional information being added to the health record.
Alternate signature: see proxy signature.
Amendment: documentation meant to clarify health information within a health record. An amendment is made after the original documentation has been completed by the provider. All amendments should be timely and bear the current date of documentation.
American Society for Testing and Materials (ASTM): a nonprofit organization that provides a forum for the development and publication of voluntary consensus standards for materials, products, systems, and services. More than 20,000 members representing producers, users, ultimate consumers, and representatives of government and academia develop documents that serve as a basis for manufacturing, procurement, and regulatory activities.
Ancillary signatures: signatures from other healthcare providers such as laboratory, radiology, respiratory, therapies, and pharmacy.
Append: the act of adding information to documentation already in existence.
Attestation: the act of applying an electronic signature to content showing authorship and legal responsibility for a particular unit of information.
Attributes: characteristics defining properties of a file, such as “read only.”
Augmentation: see correction.
Authentication: the security process of verifying a user’s identity with the system and then authorizing the individual to access the system (the sign-on process). Authentication shows authorship and assigns responsibility for an act, event, condition, opinion, or diagnosis.
Authorship: attributing the origination or creation of a particular unit of information to a specific individual or entity acting at a particular time.
Auto-attestation: the process by which a physician or other practitioner attests an entry that he or she cannot review because it has not yet been transcribed or the electronic entry cannot be displayed. This process should be strictly prohibited from use as a method of authentication in a health record.
Biometric signature: use of biological data, such as fingerprints, handprints, retinal scans, and pen strokes, to authenticate an individual.
Closed note: documentation (or note) that has been closed due to system requirement or after a defined period of time. See final note.
Complete: a note or record that has been attested. See final note.
Completion: the process of completing an entry in the health record by electronically applying the author’s signature. Once the signature is applied the entry is considered complete and the only opportunity to make changes is through an amendment. Organizational policy should define documentation points required for completing an entry and how long documents are available in an incomplete status.
Correction: a change in the information that is meant to clarify inaccuracies after the original documentation has been signed or rendered complete. Synonym: augmentation.
Counter signature or cosignature: an additional signature, electronically affixed, in those instances where state or federal law, academic teaching programs, facility guidelines, or clinical preference call for multiple attestations on a particular unit of information. For example, a resident may dictate, edit, and sign a document to indicate authorship. The responsible supervising physician may be required to sign the document in addition to the resident. Synonym: dual signature.
Data integrity: the assurance that information has not been modified between the time it is sent by the sender and received by the intended recipient. Measures taken to ensure integrity include controlling the physical environment of networked terminals and servers, restricting access to data, and maintaining rigorous authentication practices.
Drug Enforcement Administration number: a series of numbers assigned to a healthcare providers (such as a medical practitioner, dentist, or veterinarian) allowing them to write prescriptions for controlled substances. Legally the DEA number is solely to be used for tracking controlled substances. However, the DEA number is often used by the industry as a general “prescriber” number that is a unique identifier for anyone who can prescribe medication. It contains two letters, six numbers, and one check digit.
Deletion: the act of eliminating information from previously closed documentation without substituting new information.
Digital certificate: an electronic “credit card” that establishes a user’s credentials when doing business or other transactions on the Internet. It is issued by a certification authority. It contains a user’s name, a serial number, expiration dates, a copy of the certificate holder's public key (used for encrypting messages and digital signatures), and the digital signature of the certificate-issuing authority so that a recipient can verify that the certificate is real. Some digital certificates conform to standard X.509. Digital certificates can be kept in registries so that authenticating users can look up other users’ public keys.
Digital signature: a cryptographic signature (a digital key) that authenticates the user, provides nonrepudiation, and ensures message integrity. A digital signature is the strongest signature because it protects the signature by a type of “tamper-proof seal” that breaks if the message content were to be altered.
Digital Signature Standard (DSS): a standard that specifies a digital signature algorithm used to generate and verify a digital signature. Digital signatures are used to detect unauthorized modifications to data and to authenticate the identity of the signatory. In addition, the recipient of signed data can use a digital signature in proving to a third party that the signature was in fact generated by the signatory. This is known as nonrepudiation since the signatory cannot, at a later time, repudiate the signature.
Digitized signature: an electronic representation of a handwritten signature. The image of a handwritten signature may be created and saved using various methods, such as using a signature pad, scanning a wet signature, or digital photography. The signature may be “captured” in real time (at the time the user applies the signature), or a previously saved image may be applied.
Documentation management system: a computer system used to control documents during their lifecycle. The system is designed to maintain data elements about each document concerning authorship, creation, review, revision, utilization, and retention.
Dual signature: see counter signature or cosignature.
Electronic health record (EHR): a longitudinal electronic record of patient health information generated by one or more systems in any healthcare delivery setting.
Electronic routing: the automation of a business process, in whole or part, during which documents, information, or tasks are passed from one participant, human, or machine to another for action, according to a set of procedural rules.
Electronic signature: a generic, technology-neutral term for the various ways that an electronic record can be signed, such as a digitized image of a signature, a name typed at the end of an e-mail message by the sender, a biometric identifier, a secret code or PIN, or a digital signature.
Electronic signature pad: an electronic device used to capture written signatures and convert them to digital format. See digitized signature.
Encryption: the process of transforming text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when they reach a secure destination.
Final note: a note finalized through attestation, system requirement, or after a defined period of time per organizational policies and procedures, applicable rules and regulations, and medical staff bylaws.
Final signature: the process of applying the responsible provider’s electronic signature to documentation. Once applied, the documentation is considered complete. See completion.
Group signature: See proxy signature.
Hybrid health record: a system with functional components that include both paper and electronic documents and use both manual and electronic processes.
Incomplete: any note or record that is not complete as defined by state or federal law, facility guidelines, or clinical preference.
Invalidate: the act of declaring documentation invalid, taking away its legal force or rendering it ineffective. Documents may need to be invalidated in the electronic health record for various reasons such as wrong patient, patient left without being seen, or duplicate notes started for same appointment.
Late entry: delayed EHR documentation. The entry pertains to the regular course of business for the patient it addresses but is recorded subsequent to the usual and customary point of care documentation timeliness. The delay often creates documentation sequencing outside of normal chronological order.
Locked: the process by which a health record entry is complete. Any changes to the entry must be made through an amendment.
Metadata: data about data. Metadata describe how the data within a system are collected, who collected them, and when. Metadata are often referenced in an electronic health record’s audit trail.
Multiple signatures required: documentation requiring two (or more) official signatures (i.e., multidisciplinary treatment plan).
National provider identifier (NPI) : a 10-digit number used to identify all healthcare providers including individuals (e.g., physicians, nurses, dentists, chiropractors, physical therapists, and pharmacists) or organizations (e.g., hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, HMOs, suppliers of durable medical equipment, and pharmacies. The NPI is used to identify all providers of healthcare in HIPAA standard transactions and inpatient health records.
Nonrepudiation: a claim guaranteeing that the source of the health record documentation cannot later deny that he or she was the author.
Pending notes: see preliminary notes or reports.
Provider identification number or personal identification number (PIN): a personal identification number that can be used as a password for entry into an electronic system.
Preliminary entries or documents: documentation that is available for viewing but has not been authenticated or attested.
Provider: any staff member providing care to a patient who has privileges to treat and document within a health record.
Provider file: a file of the provider's demographic, medical licensure, DEA number, NPI number, and National Practitioner Data Bank status, kept current so the correct provider identification numbers appear on outgoing claims when they are dropped for billing.
Proxy signature: the process by which another provider is authorized to electronically sign documentation on behalf of the original author in an ongoing manner. The proxy accepts responsibility for the content of the original documentation. The use of proxy signature technology should be monitored closely for patterns of abuse. Synonyms: alternate signature and group signature.
Remote access: the ability to access a computer from a remote location. In order for a remote access connection to take place, the local machine must have the remote client software installed (such as virtual private network). Organizations may also implement clientless remote access methods that require no special client-based software. The remote machine must have the remote server software installed. A username and password are the preferred requirements to authenticate the connecting computer.
Reports: transcribed reports not generated within electronic health record.
Retracted state: the period after a document has been invalidated (see invalidate) during the version control portion of the legal health record.
Retraction: the act of correcting information that was inaccurate, invalid, or made in error and preventing its display or hiding the entry or documentation from further view.
Signature ceremony: the act of signing a document that calls to the signer’s attention the legal significance of the signer’s act.
Strong authentication: a two-factor authentication or multifactor sign-on authentication process that creates a higher level of security for granting privileges to an application. Strong authentication combines two or more independent factors of identification, such as password (something the user knows), a token (something the user has), or voice or fingerprint verification (something the use is). Strong authentication is also sometimes called “strong security.”
Two-factor authentication: a specific form of multifactor authentication. Examples include a password (something the user knows) combined with something the user is (such as a voice verification or fingerprint identification). Two-factor authentication is comprised of exactly two independent factors that are utilized together to create a stronger authentication than the use of a single factor, such as a password.
Unique physician identification number (UPIN): a number used to identify a physician who is enrolled in a Medicare program and is responsible for coordinating care of patients in a healthcare facility. The UPIN is often used to identify a physician in an abstracted document. The UPIN has been discontinued as of June 2007 and replaced with the national provider identifier (NPI).
Verification: the act of proving or disproving the subject matter or documents in question or comparing an activity, process, or product with the corresponding requirements or specifications.
Versioning: the storage and management of previous versions of a piece of information, documentation, or documents for security, diagnostics, and interest.
Virtual private network (VPN): a way to use a public telecommunication infrastructure, such as the Internet, to provide remote offices or individual users with secure access to their organization’s network. A VPN can be contrasted with an expensive system of owned or leased lines that can only be used by one organization. The goal of a VPN is to provide the organization with the same capabilities at a lower cost.
AHIMA. Pocket Glossary for Health Information Management. Chicago, IL: AHIMA, 2008.
AHIMA EHR Practice Council. “Developing a Legal Health Record Policy.” Journal of AHIMA 78, no. 9 (Oct. 2007) 93–97.
AHIMA e-HIM Work Group on Maintaining the Legal EHR. “Update: Maintaining a Legally Sound Health Record-Paper and Electronic.” Journal of AHIMA 76, no. 10 (Nov–Dec 2005) 64A–L.
American Bar Association. “Digital Signature Guidelines.” August 1, 1996. Available online at www.abanet.org/scitech/ec/isc/dsgfree.html.
Colorado Secretary of State. Uniform Electronic Transactions Act (UETA) Program. Available online at www.sos.state.co.us/pubs/UETA/UETA_Home_Page.htm.
Health Level Seven. HL7 EHR-S Records Management and Evidentiary Support Functional Profile 2009. Available online at www.hl7.org.
Veterans Health Administration. “iMedConsent.” Handbook 1004.05. Available online at http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1857.
AHIMA. "Electronic Signature, Attestation, and Authorship. Appendix D: Glossary of Terms (2009 update)." Journal of AHIMA 80, no.11 (November-December 2009)