# Documentation signatures



## cmacpc (Nov 30, 2015)

Good Morning:

Wonder if someone can shed some light on this scenario.  The CRNA's will document on the record (could be vitals on hand-off note) the and not sign off but the attending signs off. I am told by my superiors that this is acceptable. I was tought that anyone that documents in the record needs to sign the record. If the CRNA is scribbing doesn't the attending need to state this?  Is there anywhere that I can go to and print these guidelines that state the record must be signed by all that document on the record? I need black and white. I was told by my instructor to have a reliable resource.

Thank you
RM


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## dwaldman (Nov 30, 2015)

Below is from the CMS State Operations Manual, that states all entries in the medical record must be signed, dated, and timed:

"All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided"


If the CRNA providing a service to the patient and documented within a hospital medical record, it would be required of them by CMS regulations to authenticate that entry.


https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf


50 (Rev. 47, Issued: 06-05-09, Effective/Implementation: 06-05-09) ?482.24(c)(1) - *All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures*.  
Interpretive Guidelines ?482.24(c)(1)   
All entries in the medical record must be legible.  Orders, progress notes, nursing notes, or other entries in the medical record that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events.  
All entries in the medical record must be complete.  A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.  With these criteria in mind, an individual entry into the medical record must contain sufficient information on the matter that is the subject of the entry to permit the medical record to satisfy the completeness standard.  
All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided. 
? The time and date of each entry (orders, reports, notes, etc.) must be accurately documented.  Timing establishes when an order was given, when an activity happened or when an activity is to take place.  Timing and dating entries is necessary for patient safety and quality of care.  Timing and dating of entries establishes a baseline for future actions or assessments and establishes a timeline of events.  Many patient interventions or assessments are based on time intervals or timelines of various signs, symptoms, or events. (71 FR 68687)  
? The hospital must have a method to establish the identity of the author of each entry.  This would include verification of the author of faxed orders/entries or computer entries.  
? The hospital must have a method to require that each author takes a specific action to verify that the entry being authenticated is his/her entry or that he/she is responsible for the entry, and that the entry is accurate.  
The requirements for dating and timing do not apply to orders or prescriptions that are generated outside of the hospital until they are presented to the hospital at the time of service.  Once the hospital begins processing such an order or prescription, it is responsible for ensuring that the implementation of the order or prescription by the hospital is promptly dated, and timed in the patient?s medical record.  
When a practitioner is using a preprinted order set, the ordering practitioner may be in compliance with the requirement at ?482.24(c)(1) to date, time, and authenticate an order if the practitioner accomplishes the following:  
? Last page:  Sign, date, and time the last page of the orders, with the last page also identifying the total number of pages in the order set.  
? Pages with Internal Selections:  Sign or initial any other (internal) pages of the order set where selections or changes have been made.  o The practitioner should initial/sign the top or bottom of the pertinent page(s);and  o The practitioner should also initial each place in the preprinted order set where changes, such as additions, deletions, or strike-outs of components that do not apply, have been made.  ? It is not necessary to initial every preprinted box that is checked to indicate selection of an order option, so long as there are no changes made to the option(s) selected.  
In the case of a pre-established electronic order set, the same principles would apply, so that the practitioner would date, time and authenticate the final order that resulted from the electronic selection/annotation process, with the exception that pages with internal changes would not need to be initialed or signed if they are part of an integrated single electronic document.  
Authentication of medical record entries may include written signatures, initials, 
computer key, or other code.  For authentication, in written or electronic form, a method must be established to identify the author.  When rubber stamps or electronic authorizations are used for authentication, the hospital must have policies and procedures to ensure that such stamps or authorizations are used only by the individuals whose signature they represent.  There shall be no delegation of stamps or authentication codes to another individual.  It should be noted that some insurers and other payers may have a policy prohibiting the use of rubber stamps as a means of authenticating the medical records that support a claim for payment.  Medicare payment policy, for example, no longer permits such use of rubber stamps.  Thus, while the use of a rubber stamp for signature authentication is not prohibited under the CoPs and analysis of the rubber stamp method per se is not an element of the survey process, hospitals may wish to eliminate their usage in order to avoid denial of claims for payment.  
Where an electronic medical record is in use, the hospital must demonstrate how it prevents alterations of record entries after they have been authenticated.  Information needed to review an electronic medical record, including pertinent codes and security features, must be readily available to surveyors to permit their review of sampled medical records while on-site in the hospital.  
When State law and/or hospital policy requires that entries in the medical record made by residents or non-physicians be countersigned by supervisory or attending medical staff members, then the medical staff rules and regulations must address counter-signature requirements and processes.  
A system of auto-authentication in which a physician or other practitioner authenticates an entry that he or she cannot review, e.g., because it has not yet been transcribed, or the electronic entry cannot be displayed, is not consistent with these requirements. There must be a method of determining that the practitioner did, in fact, authenticate the entry after it was created.  In addition, failure to disapprove an entry within a specific time period is not acceptable as authentication.  
The practitioner must separately date and time his/her signature authenticating an entry, even though there may already be a date and time on the document, since the latter may not reflect when the entry was authenticated.  For certain electronically-generated documents, where the date and time that the physician reviewed the electronic transcription is automatically printed on the document, the requirements of this section would be satisfied.  However, if the electronically-generated document only prints the date and time that an event occurred (e.g., EKG printouts, lab results, etc.) and does not print the date and time that the practitioner actually reviewed the document, then the practitioner must either authenticate, date, and time this document itself or incorporate an acknowledgment that the document was reviewed into another document (such as the H&P, a progress note, etc.), which would then be authenticated, dated, and timed by the practitioner.  
Survey Procedures ?482.24(c)(1)  
 Review a sample of open and closed medical records.  
? Determine whether all medical record entries are legible.  Are they clearly written in such a way that they are not likely to be misread or misinterpreted?   
? Determine whether orders, progress notes, nursing notes, or other entries in the medical record are complete.  Does the medical record contain sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers?  
? Determine whether medical record entries are dated, timed, and appropriately authenticated by the person who is responsible for ordering, providing, or evaluating the service provided.  
? Determine whether all orders, including verbal orders, are written in the medical record and signed by the practitioner who is caring for the patient and who is authorized by hospital policy and in accordance with State law to write orders.  
? Determine whether the hospital has a means for verifying signatures, both written and electronic, written initials, codes, and stamps when such are used for authorship identification.  For electronic medical records, ask the hospital to demonstrate the security features that maintain the integrity of entries and verification of electronic signatures and authorizations.  Examine the hospital?s policies and procedures for using the system, and determine if documents are being authenticated after they are created.   



http://www.aana.com/advocacy/federa...ges/Medicare-Conditions-of-Participation.aspx


Medicare CoPs and Interpretive Guidelines 

What Is This?
It is important for CRNAs to know and have access to federal regulations that impact nurse anesthesia practice and reimbursement.



Medicare conditions of participation, or CoP, are federal regulations with which particular healthcare facilities must comply in order to participate ? that is, receive funding from ? the Medicare and Medicaid programs, the largest payors for healthcare in the U.S. CoP are published in the Code of Federal Regulations or CFR; one may identify or ?cite? them by their title in the CFR and their section or paragraph by number. The importance of the CoP for CRNAs is straightforward: The Medicare hospital CoP for anesthesia services, for example, provides both the federal requirement that CRNAs in Medicare hospitals be supervised by an operating practitioner or anesthesiologist, and the process by which a state may opt-out of that requirement.



Medicare interpretive guidelines are used by sate survey agencies (also known as SAs, which are usually state departments of health) to ascertain healthcare facilities? compliance with the CoP. Such SAs survey healthcare facilities on two conditions: to determine the facility?s eligibility to participate in the Medicare program if it is not otherwise accredited by a ?deemed status? entity such as the Joint Commission on the Accreditation of Hospital Organizations (JCAHO), and to audit healthcare facilities already accredited. According to the Government Accountability Office (GAO), SAs survey about 5 percent of a state?s hospitals in a given year. Medicare has provided SAs such interpretive guidelines for many years; however, CMS? action to publish them online in May 2004 has brought increased scrutiny to the guidelines by AANA, CRNAs and hospitals. The importance of the interpretive guidelines to CRNAs is that at a practical level SA surveyors use them to ascertain facilities? compliance with the CoP. Interpretive guidelines are identified either by the citation of their respective CoP in the Code of Federal Regulations, or by their heading or ?Tag? number under which they appear in their respective CMS manual or appendix.



CMS is the Centers for Medicare & Medicaid Services, the federal agency that administers these important federal programs. Its website is http://www.cms.hhs.gov.



CMS has described its compliance relationships with healthcare facilities as follows (from 70 FR 15267, 3/25/2005):





The CoPs are the requirements that hospitals must meet to participate in the Medicare and Medicaid programs. The CoPs are intended to protect patient health and safety and to ensure that high quality care is provided to all patients.



Sections 1861(e)(1) through 1861(e)(8) of the Act define the term "hospital"' and list the requirements that a hospital must meet to be eligible for Medicare participation. Section 1861(e)(9) of the Act specifies that a hospital must also meet such other requirements as the Secretary of Health and Human Services (the Secretary) finds necessary in the interest of the health and safety of the hospital's patients. Under this authority, the Secretary has established in regulations, at Part 482, the requirements that a hospital must meet to participate in the Medicare program.



Compliance is determined by State survey agencies (SAs) or accreditation organizations. The SAs, in accordance with section 1864 of the Social Security Act (the Act), survey hospitals to assess compliance with the CoPs. The SAs conduct surveys using the State Operations Manual (SOM) (Centers for Medicare & Medicaid Services (CMS) Publication No. 7). The SOM contains the regulatory language of the CoPs as well as interpretive guidelines and survey procedures that give guidance on how to assess provider compliance. Under Sec. 489.10(d), the SAs determine whether a hospital meets the CoPs and make corresponding recommendations to us about a hospital's certification, (that is, whether a hospital has met the standards required to provide Medicare and Medicaid services and receive Federal and State reimbursement).



Under section 1865 of the Act, hospitals that are accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the American Osteopathic Association (AOA), and other national accreditation programs approved by us are deemed to meet the requirements in the CoPs. Therefore, accredited hospitals are not routinely surveyed by SAs for compliance with the CoPs but are deemed to meet most of the hospital CoPs based on their accreditation. (See 42 CFR Part 488, ``Survey Certification, and Enforcement Procedures''). However, all Medicare- and Medicaid-participating hospitals are required to be in compliance with our CoPs regardless of their accreditation status.



Hospitals
?Medicare Hospital Condition of Participation:  Anesthesia Services (42 CFR ?482.52)
?Hospital Conditions of Participation: Anesthesia Services Interpretive Guidelines. Medicare State Operations Manual, Appendix A ? Survey Protocol, Regulations and Interpretive Guidelines for Hospitals 
?Previous Medicare Hospital Conditions of Participation: Anesthesia Services Interpretive Guidelines. Medicare State Operations Manual, Appendix A ? Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 1 05-21-04).
?State Operations Manual, pages 275-281 only address anesthesia services
?Interim guidelines published April 29, 2005, on matters relating to supervision, supersede the portion of the above guidelines under the heading (?Tag?) A-417. These interim guidelines include new or moved language in underline.


Critical Access Hospitals (CAH)
?Medicare Critical Access Hospital (CAH) Condition of Participation: Surgical services (42 CFR ?485.639(b), (c), (d) and (e)).
?Medicare Critical Access Hospital (CAH) Condition of Participation: Surgical Services Interpretive Guidelines (42 CFR ?482.52). Medicare State Operations Manual, Appendix W ? Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs) and Swing-Beds in CAHs ? (Rev. 05-21-04).
◦State Operations Manual, pages 130-143 only address anesthesia issues specifically.
◦Interim guidelines published April 29, 2005. To the extent that CMS? hospital and CAH conditions of participation are identical, so too are their respective interpretive guidelines. Thus, CMS states the updated guideline affecting practice of nurse anesthesia in CAHs at 42 CFR ?485.639(c)(2), tag #C-0323, is the same guideline as for hospitals.


Ambulatory Surgical Centers (ASCs)
?Medicare Ambulatory Surgical Center Condition of Participation: Surgical services. (42 CFR ?416.42).
?Medicare State Operations Manual, Appendix L ? Guidance to Surveyors: Ambulatory Surgical Services? (Rev. 56, 12-30-09).


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## cmacpc (Dec 1, 2015)

*documentation signatures*

I want to thank you sooooo much for the information.  This group of anesthesiologist is giving me such grief, i am at the end of my rope. As they say I don't make the rules I just follow them! 

Again, thank you,
RM


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## slgarland (Jan 12, 2016)

This thread is very helpful! we are having frequent discussion about the use of mid level providers on 99291s in my office


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