Medicare Compliance & Reimbursement

Confused? Get the inside line from state surveyors.

The use of electronic signatures for clinical records is gaining popularity in long-term care facilities. But the Centers for Medicare & Medicaid Service may not be keeping pace with change.

A Sept. 9 memo to state survey directors (S&C-04-46) says that CMS has received repeated requests for authorization to use e-signatures on the minimum data set and the individual health record. However, current CMS requirements to retain hard copies are problematic to both facility staff members and reviewers.

"Conflicting messages exist in current CMS policy, as guidance requires the need for a hard copy of all MDS forms whether or not the facility's clinical record is entirely electronic," according to the memo. In other instances, CMS allows the use of e-signatures rather than a hard copy. 

What it all means: Effective Oct. 15, CMS says that long-term-care providers who want to implement or accept the use of e-signatures for their clinical record documentation including the MDS must make sure that:

state and local law permit it;

the facility's policy authorizes it; 

procedures are in place to identify those who are authorized to sign electronically; and 

safeguards exist to prevent unauthorized use.

Lesson Learned: SNFs may want to double-check their policy - and their states' - to assure the use of e-signatures will pass muster with state surveyors.