Introduction: Signature’s Requirements
Medicare requires that services provided/ordered be authenticated by the author. The signature for each entry must be legible and should include the practitioner’s first and last name. For clarification purposes, we recommend you include your applicable credentials (e.g., P.A., D.O., or M.D.).
The Centers for Medicare and Medicaid Services (CMS) recently updated the Medicare Program Integrity Manual, Chapter 3, Section 188.8.131.52, include these acceptable electronic signatures:
Provider signatures need to meet the criteria during audits and claim reviews. Previously, CMS had clarified that "services provided/ordered be authenticated by the author," either by a handwritten or electronic signature. Stamp signatures are not acceptable under any circumstances. This means some of the old stand-by practices used also need to be updated.
chart "accepted by" with the provider's name,
"electronically signed by" with the provider's name,
"verified by" with the provider's name,
"reviewed by" with the provider's name,
"released by" with the provider's name,
"signed before import by" with the provider's name,
digitalized signature handwritten and scanned into the computer,
"this is an electronically verified report by John Smith, MD,"
"authenticated by John Smith, MD,"
"authorized by John Smith, MD,"
"digital signature: John Smith, MD,"
"confirmed by" with the provider's name,
"closed by" with the provider's name,
"finalized by" with the provider's name, and
"electronically approved by" with the provider's name.
"Signature Derived from Controlled Access Password"
Electronic Medical Records: Recommendations
The electronic system you select should include a process that verifies the individual signing his/her name has reviewed the contents of the entry and determined it contains what he/she intended.
Safeguards must be in place to protect against unauthorized access and inappropriate use of your electronic signatures, by whatever method, by anyone other than the designated individual to whom it is assigned. It is to be unique to the individual, and not reassigned nor reused by someone else. Furthermore, measures should be in place to protect the 'links' between electronic health information and signatures which prevent unapproved alteration through removal, copying or transfer.
The Medicare Program Integrity Manual, Chapter 3, explains Medicare’s signature requirements:
Electronic signatures usually contain date and timestamps and include printed statements (e.g., 'electronically signed by' or 'verified/reviewed by') followed by the practitioner’s name and preferably a professional designation. Note that the responsibility and authorship related to the signature should be clearly defined in the record.
Digital signatures are an electronic method of a written signature that is typically generated by special encrypted software that allows for sole usage
Note: Be aware that electronic and digital signatures are not the same as 'auto-authentication' or 'auto-signature' systems, some of which do not mandate or permit the provider to review an entry before signing. Indications that a document has been 'Signed but not read' are not acceptable.
CMS: Electronic Signatures
Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products that are protected against modification, etc., and should apply adequate
administrative procedures that correspond to recognized standards and laws.
The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided. Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods.
CMS: Electronic Prescribing
Electronic prescribing (e-prescribing) is the transmission of prescription or prescription-related information through electronic media. E-prescribing takes place between a prescriber and dispenser, pharmacy benefit manager (PBM), or health plan. It can take place directly or through an e-prescribing network. With e-prescribing, health care professionals can electronically transmit both new prescriptions and responses to renewal requests to a pharmacy without having to write or fax the prescription. E-prescribing can save time, enhance office and pharmacy productivity, and improve beneficiary safety and quality of care.
A “qualified” e-prescribing system is one that meets the Medicare Part D requirements described in 42 CFR 423.160 (Standards for Electronic Prescribing).