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Medical Justice

Making healthcare safe for doctors


Healthcare Reform

Those Pesky Signatures

01/29/16 11:56 AM

How many of us has received the dreaded notice that medical records are not complete; or worse, that records are complete but need to be signed. The absence of a “proper” signature gums up the works for getting paid.

This following is what CMS considers to be a valid signed order/record.

I won’t belabor the obvious.

 

If your signature is legible, you’re done.

If not, your illegible signature should be “connected” to something written or typewritten which is legible. Such as your legible printed name, letterhead, etc. If you are in a group and every doctor is listed in the letterhead, you’ll need to circle your name. Really. (Again, if your signature IS legible, you’re done and don’t need to worry about this.)

You have the alternative to submitting a signature log which gives meaning to your illegible signature.

Finally, something called an attestation will work. Here’s a sample attestation.

“I,  _____  [print full name of the physician/practitioner]  ___  , hereby attest that the medical record entry for _____  [date of service]  ___  accurately reflects signatures/notations that I made in my capacity as _____  [insert provider credentials, e.g., M.D.]  __when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

Guess what? An attestation has to be signed. Seems circular.

Alternatively, what about electronic signatures?

Yes, those are acceptable as long as it cannot be “tampered with” – and there’s an audit trail. EMRs typically address this just fine.

Interestingly, if you’ve ever sent a check to the IRS without your signature, legible or otherwise, the field office is instructed to submit for processing.

“Verify that an authorized signature appears on the check or money order. However, if the remittance is unsigned, and the taxpayer is not available to sign the check or money order, the unsigned check should be submitted for processing.”

Your bank may complete the transaction.

Out of our collective chicken scratches have sprung a litany of rules. Is this a self-inflicted wound? What do you think?

Posted by Medical Justice | in Healthcare Reform | 1 Comment »
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Michael Lieberman
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Michael Lieberman

Question: In a one man office, where I am the ONLY person making entries in a chart, is a signature really necessary at all? Can a signed pre-printed attestation cover the entire record?