Physician’s signature

The patient’s medical record is considered incomplete without authentication in the chart.

A large ophthalmic clinic with numerous providers uses scribes assigned to individual physicians. One provider in the group frequently exits the exam room without signing the patient’s chart note. The practice’s compliance officer instructed the scribe to make sure that the provider signs the patient’s chart note before submitting the encounter form to the billing office.

Why is the physician’s signature required in the patient’s chart?

The patient’s medical record is considered incomplete without authentication that the information is a true and accurate representation of the service provided. In most practices, support staff perform some portions of the patient encounter. The physician’s signature indicates that the work performed “incident to” the physician’s work is consistent and complements the physician’s findings.

When a scribe documents the entire encounter, the physician’s signature substantiates that the scribe properly documented the findings. The signature requirement extends to all physicians, including solo practitioners who document the entire service in the medical record.

The basic principles of chart documentation published by the American Medical Association include a signature component. These principles apply to all types of medical and surgical services and include the following:

The medical record should be complete and legible, and
Each encounter should include date of service, subjective complaint, history relevant to the complaint, exam findings, assessment, plan and legible identity of provider (ie, signature).

In addition, CMS Publication 100-08, amending the Medicare Program Integrity Manual, Chapter 3, §3.4.1.1B, added information regarding signature requirements effective Jan. 1, 2004. It states the following:

“Medicare requires a legible identity for services provided/ordered. The method used (eg, handwritten, electronic or signature stamp) to sign an order or other medical record documentation for medical review purposes in determining coverage is not a relevant factor. Rather, an indication of a signature in some form needs to be present.

“Providers using alternative signature methods (eg, a signature stamp) should recognize that there is a potential for misuse or abuse with a signature stamp or other alternate signature methods. For example, a rubber stamped signature is much less secure than other modes of signature identification. The individual whose name is on the alternate signature method bears the responsibility for the authenticity of the information being attested to. Physicians should check with their attorneys and malpractice insurers in regard to the use of alternative signature methods …”

As practices consider an electronic medical record system, the authentication of the chart note requires some thought. Does the system include a form of authentication by an individual provider? Is it password protected? Is it possible to alter a chart note without detection? The vendor should address these concerns before purchasing an electronic medical record system.

As an added compliance step, the practice can develop a master reference containing representative signatures for each physician. If a third-party questions the authenticity of a signature in a medical record, this master list serves to authenticate it. Some practices also include technicians’ signatures in this master reference to further describe signatures appearing in the patient’s medical record.

Bottom line — continue to insist that the physician sign the patient’s chart to ensure compliance with complete medical records.