Documentation guidelines for physicians and other professional providers updated

Revised signature requirements, including those for Centers for Medicare & Medicaid Services, were recently incorporated into document guidelines and provider manuals for physicians and other providers. Here’s an overview of the updates.

Medical record entries
Each entry, such as verbal orders and instructions, prescriptions and telephone consultations, must include:

• The date the information is documented and the specific time when relevant.
• A legible signature that can be easily authenticated. Blue Cross Blue Shield of Michigan accepts written (cursive or printed) and electronic signatures. Stamped signatures are not acceptable.
  • For electronic signatures, the system must authenticate the signature at the end of each note. An acceptable electronic signature includes a lead-in phrase, such as, “electronically signed by,” “authenticated by,” “approved by,” “completed by,” “finalized by,” or “validated by,” followed by the provider’s name, credentials and the date signed. The process must be password protected and used exclusively by the individual physician.
• Credentials, like M.D. or D.O., should be written after a provider’s name unless his or her credentials are included on the stationery of the accompanying note.

Note: All providers of mental health and substance abuse services must include their credentials (for example, John Smith, Ph.D.). Other physicians (who don’t provide mental health and substance abuse services) are not required to include credentials.

Medical record pages

• Each page of a medical record, including test data and reports, must include patient identification, either the patient name or provider-designated patient ID number.
• All diagnostic imaging must include unique patient identification and the date of service as a permanent part of the image.

The documentation guidelines can be found in your provider manuals in the chapter titled “Documentation Guidelines” and also on web-DENIS. We’ll notify you about future guideline updates in The Record and on web-DENIS.

If you have any questions, contact your provider consultant.