Therapy EMR Signature Regulations: Compliance Made Easy!
The Centers for Medicare and Medicaid Services (CMS) require a legible identifier and date in the documentation of each encounter for patient services ordered and provided. Therapists have some choices in how they can accomplish this task. They can use various methods to capture their signatures for medical review purposes including hand written and electronic signatures.
Well designed procedures and sophisticated therapy software systems will ensure that your clinical documentation “stands up” to medical review, complies fully with HIPAA regulations, and protects the electronic health records of your patients. Know the rules …..
Signature stamps are not accepted by CMS. All clinical documentation must include an actual therapist signature.
If a therapist’s “mark” or “sign” is not a clear indication of the author and is not affixed over the typed or printed name, then an attestation “statement of authenticity” or a “signature log” must accompany all medical records being reviewed.
CMS does not mandate a specific attestation format but suggests: “I, [therapist name], hereby attest that the medical record entry for [date range] accurately reflects signatures and notations that I made in my capacity as [provider credentials] when I treated and/or diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate, and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material facts may subject me to administrative, civil, or criminal liability.”
“Medical reviewers shall not consider attestation statements from someone other than the author of the medical record entry in question.” (Source: Program Integrity Manual, Chap 3, Sect 184.108.40.206D)
Providers should keep a signature log for illegible and electronic signatures with the typed or printed name of the author, their initials, electronic signature, or illegible signature. Providers are encouraged to list the credentials of their clinicians (e.g., PT, OTR, or SLP).
Unsigned documents with the provider’s name typed in only do not meet the requirements for medical review, nor do indications that the therapists’ “signatures are on file.” The signature log or attestation statement must accompany all clinical documents submitted.
Therapy systems with electronic signatures require features to prevent signature modification, restrict signature access to the treating therapist only, allow for a supervisory signature, and correspond to recognized standards and laws. Providers using EMR systems should obtain an electronic signature from each therapist, especially PRN or part-time therapists who visit the facility on an irregular or infrequent basis. Capturing their hand written signatures on clinical documents when they are gone is difficult if not impossible.
CarePoint Therapy Management Software has the capability of inserting the therapist’s electronic signature over the printed name with every clinical document created. This eliminates the work of signing all clinical documents manually. The signature log remains in the facility and medical review compliance is accomplished without additional supporting paperwork. CarePoint complies fully with HIPAA regulations for the protection of electronic health records.