| Q: |
What is required for a valid signature? |
| A: |
- Services provided or ordered must be authenticated by the ordering practitioner
- Handwritten or electronic signatures (stamped signatures are not acceptable)
- Legible Signatures
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| Q: |
What should I do if I haven’t signed a medical record? |
| A: |
You cannot add late signatures to medical records (beyond the short delay that occurs during the transcription process). If the practitioner’s signature is missing from the medical record, submit an attestation statement from the author or the medical record. See a sample attestation statement below. |
| Q: |
What if the physician signs the progress note, but the signature is illegible? |
| A: |
You may submit a signature log or attestation statement to identify the illegible signature. A printed name below the illegible signature on the original record may be acceptable. |
| Q: |
Are initials acceptable as a signature? |
| A: |
You may submit a signature log or attestation statement to identify the initials. A printed name below the initials on the original record may be acceptable. |
| Q: |
What is a signature log? |
| A: |
A signature log is a typed list of all providers that displays each provider’s name with a corresponding handwritten signature. The log may be for an individual or a group. A signature log is used to establish signature identity as needed throughout the medical record documentation process. |
| Q: |
What if I do not currently have a signature log in place? |
| A: |
You may create a signature log at any time. Medicare contractors accept all signature logs submitted regardless of the date created. |
| Q: |
Can I attest to my own signature? |
| A: |
Yes. A signature attestation is a statement signed and dated by the author of the medical record entry. It must contain sufficient information to identify the beneficiary. A sample attestation statement can be found below. |
| Q: |
Do signatures need to be dated? |
| A: |
Documentation must contain enough information to determine the date on which the service was performed or ordered. If the entry immediately above or below the signature is dated, medical reviewers may reasonably assume the date of the signature in question is the same. |
| Q: |
What are the guidelines for using an electronic signature? |
| A: |
- Systems and software products must include protections against modification; apply administrative safeguards that correspond to standards and laws.
- The individual named on the alternate signature method and the provider bear the responsibility for the authenticity of the attested information.
- Physicians are encouraged to check with their attorneys and malpractice insurers with regard to the use of alternative signature methods.
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| Q: |
Can my name be printed by the software without a signature? |
| A: |
No. An unsigned, typed note with the provider’s name only does not meet the requirement. |