Who is responsible for the authorship of a patient record entry?

The health-care provider making the entry is responsible for the authorship of a patient record entry because they are the individuals directly involved in delivering care and documenting pertinent information regarding the patient's treatment. This responsibility stems from the legal and ethical obligation of healthcare professionals to maintain accurate, complete, and timely records that reflect the care provided.

Health-care providers, such as physicians, nurses, or allied health professionals, have the knowledge and expertise to evaluate patient information and document necessary details about diagnoses, treatments, and patient responses. This documentation contributes not only to the continuity of care but also to legal accountability and professional standards within the healthcare system.

While patients have an essential role in providing information about their health and care preferences, they do not have the professional training to validate or interpret clinical information. Similarly, administrative staff may handle records for billing and coding purposes, but their functions do not entail the professional input required for clinical documentation. Finally, while a healthcare organization may have policies in place regarding record management and documentation practices, it is ultimately the responsibility of the individual provider who makes the entry to ensure its accuracy, completeness, and compliance with legal and ethical standards.