Practice Management Alert
Incomplete Documentation
Question: I have been attending different audit meetings and am repeatedly told that if the doctor doesn't sign his or her notes that the note is incomplete. One of my physicians showed me a note from a medical society stating that there is no law and that it is only recommended. Is this true? New Hampshire Subscriber Answer: There are varied signature requirements mandated by different insurance carriers and other organizations, such as JCAHO (Joint Commission on Accreditation of Healthcare Organizations). For example, JCAHO will accept an electronic signature, but other organizations may require a handwritten one. For federal billing, as referenced in the OIG (Office of Inspector General) Compliance Program Guidance for Individual and Small Group Physicians, "The documentation of each patient encounter includes the reason for the encounter; any relevant history; physical examination findings; prior diagnostic test results; assessment, clinical impression, or diagnosis; plan of care; and date and legible identity of the observer." (You can view the full report at http://oig.hhs.gov/authorities/docs/ physician.pdf.) The note is therefore considered incomplete if the identity of the servicing provider is not evidenced.
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