Lately I’ve had several questions come up from clients regarding signature requirements for documentation. Just last month CMS released a Medicare Learning Network (MLM) Matters article on the topic. Check out pages 12 and 13 of this related document for examples of what reviewers use to determine if the signature requirement is met. Also, notice on page 13 the very vague, in my opinion, statement regarding electronic signatures:
2. Electronic Signatures
Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products which are protected against modification, etc., and should apply administrative procedures which are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bears the responsibility for the authenticity of the information being attested to. Physicians are encouraged to check with their attorneys and malpractice insurers in regard to the use of alternative signature methods.
Good thing ACOM Health’s Rapid Doc software allows doctors to physically sign each note using a tablet PC so there is no question as to authenticity, or a need to check with an attorney!
