Primary Care Coding Alert

Question: We’re having trouble making sure our providers meet signature requirements for their charts and labs. Can we include each physician’s name at the bottom of our chart and leave space for them to sign and date above their name? For labs or other correspondence that comes in, can each physician use a stamp of his printed name and credentials, then sign above where he stamps? I know we can’t use a signature stamp, but am not sure about these other options. 

Michigan Subscriber 

Answer: The physician can sign his office visit notes however he pleases, provided it isn’t over a written name with credentials. You should also have a signature log on file in the office that includes any potential ways the physician could sign a chart or note. For example, Dr. Darren Smith sometimes signs his charts as “Dr. D. Smith,” “D. Smith, M.D.,” “D.S.,” or “Darren Smith, M.D.” The signature log must include each of those signatures or initials so you can provide the information to auditors as needed.

Caveat: The only exception would be if the applicable regulation, NCD, LCD, or payer manual has specific signature requirements. In that case, the specified requirements would take precedence.