By: Lorna Simons, CPC
Medco Consultants, Inc
How do you know if the signature on your health records is valid? Before working in medical coding, I had assumed that all signatures, even the most ill-defined were valid. We all know too well the jokes about doctor’s handwriting. However, the Center’s for Medicare and Medicaid Services (CMS) has certain requirements for physician signatures to be valid.
Signatures can be either handwritten or electronic. Signature stamps are only permissible if the provider suffers from a physical disability and can prove that they are incapable of signing a patient note due to disability.
Handwritten signatures must be legible. If the signature is not legible, it should be accompanied by the provider’s name either printed, typed, or on the letterhead. Providers may have a signature log on file with their name typed and signed to show that the signature is their own or attest their signature if required for purposes of review.
Electronic signatures must protect against modification and have certain administrative safeguards. Once the note is signed with the electronic signature, the note should be locked and any changes and updates would have to be made with addendums. If the system does not protect the notes against modification, then the signature is invalid. Electronic signatures can be digitized (the provider’s signature in an electronic image) or statements indicating the note was signed electronically. The signature usually has a date and time stamp. It is important to note that as per the guidance provided by Palmetto GBA, “Indication that a document has been ‘signed but not read’ is not acceptable…”
Its important to remember that signatures are required to authenticate treatment/surgical notes, procedures and orders for diagnostic testing and labs. The signature must be by the treating or ordering healthcare provider.
Source:
Medicare Program Integrity Manual, Chapter 3.3.2.4- Signature Requirements, http://ow.ly/Tojl30fsL0A
Complying with Medicare Signature Requirements, http://ow.ly/lQdP30fsKPh
Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices, http://ow.ly/W2dl30fwsSI