What must be identified in health record entries?

• A. Author must be identified
• B. Date only
• C. Procedure only
• D. Diagnosis only

Answer: (A)

Author identification is essential because it links every note or entry to the clinician who created it, establishing accountability and a clear point of contact for questions or follow‑up. This traceability is crucial for ensuring the note’s integrity, assigning responsibility for the content, and meeting legal and professional standards. While recording the date and the specific content (what was done, diagnosed, or ordered) is also important, without identifying the author you cannot verify responsibility or request clarification. In practice, entries are signed or electronically authenticated by the author, along with their credentials, to ensure proper attribution.