04/20/2016    

E-HEALTH NEWS

Signature Log Can Be the Key to Surviving an Audit

 

All medical records need to be signed, whether they are paper or electronic. A common reason for failing an audit is unsigned medical records. When using your EHR system, please be sure to sign your notes in a timely manner. Each time you sign your record electronically, a time/date stamp is placed into your record that memorializes the time and date you signed the record. A large gap between the date of service and date of the signature can result in questions regarding the authenticity and accuracy of the signed record.

 

Paper records also require signatures. With a paper record, there are times when a signature may not be legible. For paper records, a signature log is very important and should be kept. This can be especially useful should a provider leave the practice, since that provider will no longer be available to authenticate his/her signature. A signature log is a typed listing of the provider(s), identifying their name(s) with a corresponding handwritten signature. This may be an individual log or a group log. A signature log may be used to establish signature identity as needed throughout the medical record documentation.

 

Source: Michael Brody, DPM, TLD Systems Reimbursment Update [4/18/16]