Registered Health Information Administrator (RHIA) — Question 66

Which method of identification of authorship or authentication of entries would be in appropriate to use in a patient’s health record?

Answer options

• A. written signature of the provider of care
• B. identifiable initials of a nurse writing a nursing note
• C. a unique identification code entered by the person making the report
• D. delegated use of computer key by radiology secretary

Correct answer: D

Explanation

The correct answer is D, as the delegated use of a computer key by a radiology secretary does not provide a reliable means of authentication since it lacks accountability for the actual entry. In contrast, options A, B, and C involve direct identification methods that ensure the responsible party is traceable in the patient's health record.