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Documentation:

Brush Up on Electronic Signature Rules

Published on Wed Apr 08, 2020

Don’t let a signature snafu cause issues.

Nursing facilities can utilize electronic signatures for clinical record documentation, including in the MDS, in some places, depending on state and local law, as well as the individual facility’s policy.

You know that accurate documentation is crucial, but signature issues are becoming increasingly common.

Background: Medicare requires that services provided or ordered be authenticated by the author, and the method used for authenticating would be a handwritten or electronic signature. In some situations, stamped signatures are permitted, provided that the author has a physical disability that prevents them from signing the record.

“Signature issues are among the biggest findings in the comprehensive error rate testing (CERT) and medical error rate programs,” related NGS Medicare’s Gail O’Leary during the Medicare Administrative Contractor’s (MAC’s) webinar “Medicare Signature Guidelines.”

Read on for tips on the correct usage of electronic signatures and stay ahead of the curve on Medicare documentation guidelines. As more doctors’ orders and notes are processed electronically, online, you’ll rely more and more on these e-signature basics.

Understand Role of Electronic Signatures in MDS

“Nursing homes also have the option for a resident’s clinical record to be maintained electronically rather than in hard copy. This also applies to portions of the clinical record such as the MDS. Maintenance of the MDS electronically does not require that the entire clinical record also be maintained electronically, nor does it require the use of electronic signatures,” the Resident Assessment Instrument (RAI) Manual says on page 2-7.

But know what you need to back up. “In cases where the MDS is maintained electronically without the use of electronic signatures, nursing homes must maintain, at a minimum, hard copies of signed and dated CAA(s) completion (items V0200B-C), correction completion (items X1100A-E), and assessment completion (items Z0400-Z0500) data that is resident-identifiable in the resident’s active clinical record,” says the RAI Manual.

Know When to Support Signature with Additional Documentation

Sometimes the surgeon might sign a document with an illegible signature, and that’s when you can use a signature log or attestation to demonstrate that the signature belongs to the provider in question.

“A signature log is a typed listing of the providers identifying their names with corresponding handwritten signatures. This may be an individual log or a group log,” the Centers for Medicare & Medicaid Services (CMS) says in its document, Complying With Medicare eSignature Requirements. “A signature log may be used to establish signature identity as needed throughout the medical record documentation.”

Providers might also include an attestation statement. To be considered valid by Medicare, the statement must be signed and dated by the author of the medical record entry and contain the appropriate beneficiary information.

Figure out who Signs

The author of the document should always be the person who signs the document. “This can be confusing in the electronic world, but consider that it would be odd, in a paper note, to see one provider sign another provider’s notes,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebraska. “The same rule applies in the electronic medical record (EMR). When in doubt, consider whether it makes sense for a paper record.”

That holds even in cases of an incident-to service. The person who performs the service and writes the note should sign, not the supervising physician. “However, the documentation must support evidence that the supervisor was present and available,” O’Leary stressed.

Note: “Use of electronic signatures for the MDS does not require that the entire clinical record be maintained electronically. Facilities must have written policies in place to ensure proper security measures are in place to protect the use of an electronic signature by anyone other than the person to whom the electronic signature belongs,” the RAI Manual says.

Don’t Forget Exceptions

As with most rules, some exceptions apply to the signature regulations, explained NGS Medicare’s Lori Langevin during the webinar. The first exception, she noted, is that facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.

In addition, orders for clinical diagnostic tests need not be signed, but the treating physician must have medical documentation indicating that he or she intended the clinical diagnostic test to be performed, and that documentation must be authenticated by the author via a handwritten or electronic signature.

The third exception involves other regulations and CMS instructions regarding signatures — these can have priority over the standard regulations. “In cases where the relevant regulation, NCD [National Coverage Determination], LCD [Local Coverage Determination], and CMS manuals have specific signature requirements, those signature requirements take precedence,” Langevin said.

The final exception indicates that CMS permits use of a rubber stamp for signatures in accordance with the Rehabilitation Act of 1973, which states that an author with physical disability must provide proof of their inability to sign due to their disability. In those cases, a rubber stamp would be permitted.

Know Only Some E-Signatures Work

If you’re wondering which types of e-signatures are acceptable from a Medicare standpoint, Langevin answered that by offering a few examples, as follows:

  • “Reviewed by” with provider’s name
  • “Released by” with provider’s name
  • Chart “Accepted by” with provider’s name
  • “Electronically signed by” with provider’s name
  • “Verified by” with provider’s name
  • “Signed before import by” with provider’s name
  • “Authorized by: John Smith, MD”
  • “Digital Signature: John Smith, MD”
  • Digitized signature: Handwritten and scanned into the computer
  • “This is an electronically verified report by John Smith, MD”
  • “Authenticated by John Smith, MD”
  • “Confirmed by” with provider’s name
  • “Electronically approved by” with provider’s name
  • “Closed by” with provider’s name
  • “Finalized by” with provider’s name

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