Reminder: Signature required on medical records

A signature is mandatory on medical records to identify who provided services for the patient. It also validates the services were documented, reviewed and authenticated by the provider.

Requirements for an acceptable signature depend on whether the medical record is generated by an electronic health record or is handwritten.

Services performed by nonphysician practitioners who require physician supervision must be signed by the overseeing provider. Examples of services requiring a supervising physician signature include therapeutic and behavioral health. This includes providers supervising licensed social workers, behavioral health therapists, massage therapists and registered nurses performing administration of drugs.

Electronic signatures

Electronic signatures must be generated by encrypted or password-protected software and used solely by the author of the report or record.

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 that are protected against modification, etc., and should apply adequate administrative procedures that 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. Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods.”

Electronic signatures must contain the following key elements:

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

Acceptable attestation statements include the following:

• 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)

Example (electronic signature and attestation statement):

• Electronically signed by: Eli Carson, M.D. 09/18/2023
• Approved by: Peter Wilsby, NP 08/23/2023

Unacceptable electronic signatures include the following:

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

Examples:

• Electronically signed, but not authenticated George Hudson, M.D.
• Peter Cunningham, M.D. 07/14/2023
• 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.
 
A handwritten signature is acceptable if it is:

• A fully legible signature, including credential
• A legible first initial, last name and credential
• An illegible signature, or initials, when over a typed or printed name and credential
• An illegible signature when the letterhead or other information on the page indicates the identity and credential of the signer

The Medicare Program Integrity Manual (Chapter 3) requires a handwritten signature be legible and include the provider’s credentials. An illegible signature is allowed when the letterhead or other information on the page indicates the identity and credential of the signer.

For additional guidance, refer to the Medicare Program Integrity Manual** and the June 2018 Record article, “Medical Record Signatures: What’s acceptable?”

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.