In October 2009, Cahaba GBA facilitated a webinar addressing signature requirements for medical records and provided examples of inappropriate provider signatures as well as acceptable provider signatures.
Examples of inappropriate provider signatures include:
- Stamped signatures in the medical record
- Signatures that are not legible
- Electronic record with no electronic signature and no typed signature
- Handwritten progress notes not signed
- Diagnostic testing procedures not signed
- Signatures for which the provider’s professional designation cannot be identified
Examples of acceptable provider signatures include:
- Documentation of a legible handwritten signature
- Documentation that states “electronically signed” and has a typed signature
- Documentation that states “signature on file”
- Documentation that is digitally signed
- Documentation that states “dictated by / transcribed by” (must be signed or initialed by the physician)
- Documentation that states “authenticated by”
- Documentation that states “generated by”
- Documentation that states “electronically authenticated by”
- Documentation that states “ electronic signature on file”
Other information presented in the webinar:
- Signatures on diagnostic studies, operative reports, interpretations, procedure and progress notes should be physically or electronically signed. The reports must be authenticated or acknowledged that services were ordered.
- If a CPT code for a service requires a formal report to fulfill the complete requirements of the respective code, the formal report itself must be included in the medical record.
- Services denied by Cahaba GBA or Medicare affiliated reviewers related to missing signatures may be appealed.
For more information and references, please review the attached copy of Cahaba’s slides from the webinar.