Electronic Signatures on Health Care Documents
PDF Version of DQA 11-017
(PDF, 49 KB)
Electronic Signatures on Health Care Documents
The Division of Quality Assurance (DQA) is sending this information to
DQA regulated providers for their information and use.
Background
With the development of electronic recordkeeping, various options exist
to electronically obtain and store a health care patient's or resident's
signature for necessary documents. For example:
- The patient or resident could sign a paper document that is scanned
and placed into the patient's or resident's electronic file.
- The patient or resident could sign a touchpad signature device,
similar to when a person makes a credit card purchase. The use of the
signature pad produces a graphic image of the person's signature.
- The patient or resident could independently access his/her electronic
record, using a unique User ID and password via a sequence of entries,
enter a mark that she/he adopts as his/her signature.
Question
Is there a need for a patient or resident to sign a hard copy release for
electronic health care records? If so, must the entity retain the hard copy
after scanning the hard copy and incorporating the document into the
electronic record?
Answer
A hard copy release is not required. If a paper (hard copy) release is
used, a scanned copy may be substituted as the "original" for
retention/ recordkeeping purposes. Wis. Stat. § 137.15 provides for legal
recognition of electronic records, signatures and contracts. The statute
specifically recognizes the legal effect and enforceability of signatures
and contracts in electronic format. The statute recognizes electronic
records as satisfying laws that require a record to be in writing, as well
electronic signatures as satisfying laws that require a signature.
Wis. Stat. § 137.11(8) defines "Electronic signature" to
include "an electronic sound, symbol, or process attached to or
logically associated with a record and executed or adopted by a person with
the intent to sign the record." Thus, an electronic signature could be
created by scanning a signed document and including the scanned image in the
electronic record, including the image from a touchpad signature device, or
the entry of a "signature" via use of the consumer's adopted
image, symbol or pin number.
Summary
The Wisconsin Statutes recognize the legal effect of electronic
signatures and records in transactions where the parties have agreed to
conduct the transaction by electronic means. In such transactions, there is
not a need for a patient or resident to sign a hard copy or paper document.
A binding informed consent health care release may be executed
electronically in Wisconsin.
There appears to be no legal requirement for an entity to create and
retain a hard or paper copy of an electronically signed release. Entities,
however, may have their own policy rationales for retaining copies. A bona
fide electronic or hard copy backup is required for all providers. Even if
not required, back-up alternatives would represent best practice to
preserving or protecting resident or patient information.
Under the Health Insurance Portability and Accountability Act (HIPAA) and
the Health Information Technology for Economic and Clinical Health (HITECH)
Act, covered entities must implement policies and procedures for
authentication and integrity of electronically stored health information.
For information regarding HIPAA and HITECH requirements, visit the U. S.
Department of Health and Human Services health information privacy websites
at: http://www.hhs.gov/ocr/privacy/
and http://www.hhs.gov/ocr/privacy/hipaa/administrative/enforcementrule/
hitechenforcementifr.html
If you have question about this information, please contact Dinh Tran,
DQA Social Services Consultant at (608) 266-6646 or via email at dinh.tran@dhs.wi.gov
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Last Updated: September 30, 2011
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