Compliance update--valid types of signatures in this modern era.
Proper signatures in the medical record is an area of concern because they are included in the Office of Inspector General (OIG) Compliance Guidance as a potential risk area effecting physician practices. One of the four areas identified by OIG is timely, accurate and complete documentation, which includes "date and legible identity of the observer." Federal auditors deny claims and require refunds if signatures are omitted from documentation of services. The vision of the current President is for all Americans to have Electronic Health Records (EHR) within a decade; this implies a growing use of electronic signatures. What constitutes a valid signature, and what regulations affect the use and type of signature? Businesses require signatures on many forms and documents. However, what if a check is not signed; can it be cashed? If a contract is not signed, is it binding? Similarly, if the medical record is not signed, will it withstand scrutiny in court? What is the significance of a signature? How important is it to authenticate or sign a report? To authenticate means to verify that the message/report comes from its stated source; therefore the author stands behind the documentation as written. The type of signature that is acceptable is variable, depending on the facility and the form payer requires.
Hammon
Marilyn
M
University of Oklahoma Health Science Center, Oklahoma City, USA.
D004282:Documentation / Q000592:standards; D006801:Humans; D008499:Medical Records / Q000331:legislation & jurisprudence / Q000592:standards*; D009825:Oklahoma; D014481:United States