Medical record signatures: What’s acceptable?

With everyone moving to electronic health records to meet the regulatory and insurance requirements of "meaningful use," it is important to know what the Centers for Medicare & Medicaid Services considers an acceptable signature. Of every document placed in a chart, the signature is among the most important. With this simple validation, the provider or author is verified and attests to everything that’s been written in the record about a patient. The appropriate signature depends on whether the report is generated by an electronic health record or is handwritten.

Electronic signatures

The signature commonly generated by encryption software for use solely by the author of the report or record is referred to as the electronic signature.

The Medicare Integrity Manual (Ch. 3, 3.3.2.4) states:

“Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products which are protected against modification, etc., and should apply administrative procedures which are adequate and correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided.”

Therefore, if electronic signatures are used as a form of authentication, electronic health records systems must authenticate the signature at the end of each note. This is paired with an attestation statement showing that the physician attests to everything he or she has written in the report.

An electronic signature must contain the following key elements:

• Practitioner’s name
• Credentials
• Date
• Printed attestation statement

Some examples of an acceptable attestation statement may include:

• Accepted by
• Acknowledged by
• Approved by
• Authenticated by
• Closed by
• Digitally signed by
• Electronically authored by
• Finalized by
• Generated by
• Released by
• Reviewed by
• Signed by
• Validated by
• Performed by (when exam and related documentation are performed by the same provider)

All electronic signatures are not acceptable. Some auto-authentication or auto-signature systems don’t mandate that the provider reviews an entry before signing, as it’s automatically done.

Examples of unacceptable statements from the systems described above include:

• Signature on file
• Electronically signed by agent of provider
• Signed but not read
• Electronically signed, but not authenticated
• Electronically signed, but not validated/verified

These reports are not authenticated because the content hasn’t been reviewed by the provider. See the examples below:

• Acceptable provider signatures:
• Electronically signed by: Eli Carson, M.D. 08/01/2016
• Closed by: Peter Wilsby, NP 09/16/2016

• Unacceptable signatures:
• Electronically signed, but not authenticated George Hudson, M.D.
• Peter Cunningham, M.D. 06/13/2014
• Signed Jessica Kastle (No credentials)

Handwritten signatures

Handwritten signatures may only be used on handwritten, transcribed or dictated reports. Handwritten signatures aren’t valid on reports generated from an electronic health records system.

The CMS Medicare Program Integrity Manual (Chapter 3) states that a provider’s handwritten signature is acceptable if it’s:

• A fully legible signature, including credential.
• A legible first initial, last name and credential.
• An illegible signature, or initials, is allowed when over a typed or printed name and credential.
  

• An illegible signature is allowed when the letterhead or other information on the page indicates the identity and credential of the signer.

It’s very important for provider signatures to meet this criterion. The validity and authenticity of the report can be determined by this simple signature. As stated by the CMS Medicare Program Integrity Manual, “Medicare requires that services provided/ordered be authenticated by the author.” This means that without a proper signature, the record can be deemed invalid, thus hindering patient care. If using an electronic health records system, consulting with technical staff and software vendors can ensure the integrity of your documentation and signatures.

For guidance, refer to the Medicare Program Integrity Manual.