# signature requirements for CMS



## JGiles24 (Nov 8, 2011)

I need some help. I have an MD who states that all pages in the medical record do not need to be signed/initialed. The page in question: the patient is given a form to fill out for the cheif complaint, and the locations, severity, ect of the pain.... they physician is NOT signing/initialing this page that he reviewed it. I am telling him that that page cannot be used for his E/M leveling sinced he has not signed it. I have searched CMS.gov looking for documentation on this and cannot locate. Can someone please help?


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## mhstrauss (Nov 8, 2011)

JGiles24 said:


> I need some help. I have an MD who states that all pages in the medical record do not need to be signed/initialed. The page in question: the patient is given a form to fill out for the cheif complaint, and the locations, severity, ect of the pain.... they physician is NOT signing/initialing this page that he reviewed it. I am telling him that that page cannot be used for his E/M leveling sinced he has not signed it. I have searched CMS.gov looking for documentation on this and cannot locate. Can someone please help?



http://physicianlaw.foxrothschild.c...out-medicare-physician-signature-requirements

Here's the link to an article that I think will help you...specifically the line that states "all medical records be signed by the provider"  
The article does include a link to the CMS manual that the info comes from.  Hope this helps!!


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## LLovett (Nov 8, 2011)

What is being used from that page for the E/M?

If he references the form by name and date he can use the information (PFSH and ROS) from it without having to sign and date it himself.

What I find concerning about your post though is it sounds like elements of HPI are actually being collected from the patient and not by the provider. This is unacceptable in any form. It does not matter if the provider signs the form validating the information is correct, it does not count unless they gather the information themselves and document it.

You will not find anything from CMS stating every page of the medical record has to be signed, if you do please post because it will be news to me. CMS states that providers must legibly sign and date their notes. There is no stipulation on every page. Every page is required to have two patient identifiers but other than that I am not aware of any other requirements.

Laura, CPC, CPMA, CEMC


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## camilleb (Nov 8, 2011)

I worked for a physician once, that had the patient document their HPI and he would sign each page that he reviewed the information.  This worked during a Medicare HMO audit, since the physician does not dictate his office visit notes.

I have also worked for physicians that dictate their notes, referencing the documentation of HPI that the patient completed and only signed his dictated note.

I suppose the difference would be that if he dictates or not.

Just trying to help....


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