Who should be the author of a patient record entry?

• A. The licensed professional who performed or supervised the procedure
• B. Any staff member
• C. The patient
• D. The administrator

Answer: (A)

In clinical documentation, attribution and accountability are essential: the entry should be authored by the licensed professional who performed or supervised the procedure. This ensures the notes accurately reflect the clinical actions taken, the observations made, the interpretations formed, and the rationale for decisions. The author bears responsibility for the accuracy and completeness of the record, and their licensure guarantees that the documentation meets professional and legal standards. While other staff may collect data or support care, they are not the primary author of the clinical entry when it comes to procedures. The patient should not author professional clinical notes, and an administrator’s role is typically administrative rather than clinical documentation.