25 Apr Off
From 2010 to 2014, hospital use of electronic health records (EHRs) increased to over 95 %, and physician use of EHRs increased from 25 to over 80%. The rate of use in PACE organizations is even higher. While the advancement of EHRs has many promised benefits, there are risks to program integrity that could lead to compromised patient care or violation of regulations.
We have pointed to a number of compliance issues in previous articles, and now want to draw attention to EHR signature requirements. CMS has defined specific signature requirements for authenticating services provided and ordered. These requirements include paper and electronic medical records.
The Medicare Program Integrity Manual states the acceptable methods of authentication are handwritten or electronic signatures. All signatures must include the
- Name of provider
The following are various examples of acceptable signatures.
Handwritten signatures certify the knowledge or acceptance of the information documented. The handwritten signature must be present in the document and must be legible. A signature log can be used for illegible signatures. Signature logs contain the providers typed or printed name and should also contain credentials.
Electronic signatures are signatures produced by encryption software and allow only sole usage. The purpose of this is to prevent any modification of the author’s signature.
The following are examples of acceptable electronic signatures:
- Chart ‘Accepted By’ with provider’s name
- ‘Electronically signed by’ with provider’s name
- ‘Verified by’ with provider’s name
- ‘Reviewed by’ with provider’s name
- ‘Released by’ with provider’s name
- ‘Signed by’ with provider’s name
- ‘Signed before import by’ with provider’s name
- ‘Signed: John Smith, M.D.’ with provider’s name
- Digitalized signature: Handwritten and scanned into the computer
- ‘This is an electronically verified report by John Smith, M.D.’
- ‘Authenticated by John Smith, M.D.‘
- ‘Authorized by: John Smith, M.D.‘
- ‘Digital Signature: John Smith, M.D.‘
- ‘Confirmed by’ with provider’s name
- ‘Closed by’ with provider’s name
- ‘Finalized by’ with provider’s name
Note: Simply typing a provider’s name and credentials is not an acceptable signature.
An Attestation statement is another example of a valid signature. It must be signed and dated by the provider and must identify the Medicare beneficiary. Attestations must be provided when needed for all records submitted in the event of an audit.
Rubber stamp signatures are not acceptable except in the case of an author with a disability. This method is permitted under the Rehabilitation Act of 1973.
It is important to know and understand CMS guidelines for signatures and ensure your program is meeting the requirements for paper and electronic charts.