Wiki Late signatures

[hkgordon89]

Hello,
I have several providers who have gotten in to the habit of not documenting or signing their office encounters for weeks at a time. For example, I have a patient who was seen on 6/12 but the note was not signed or documented until 7/3. Another is a study performed in the office in March but not signed until July 1st.
I’m in GA and have looked at Palmetto’s information but it is vague and doesn’t give a specific time frame for when something should be signed. It just says “Providers should not add a late signature to the medical record beyond the short delay that occurs during the transcription process.”

To my knowledge we do not have a policy in place for this type of issue and I would like advice from a compliance standpoint.

Would you still bill these encounters?

 

[Hoss234]

Here are some resources to use for your P &P which does include addressing late signatures beyond the acceptable time span of 24-72 hours for transcription to be completed.
The integrity of the medical record is in question whenever there are late entries made by a physician or other level of medical staff.

 

[Pathos]

Is there a logical and rational reason for all of these late signatures? Best practices include signing off your medical note preferably the day of the service/visit, or as soon as possible. If I was to audit a note that wasn't signed off until weeks or even months later, I would question the validity of the note. If late signatures is a habitual thing by your providers, I would get your Compliance Officer involved and develop a strategy/policy to shield your providers and practice from further compliance issues.

 

[hkgordon89]

Here are some resources to use for your P &P which does include addressing late signatures beyond the acceptable time span of 24-72 hours for transcription to be completed.
The integrity of the medical record is in question whenever there are late entries made by a physician or other level of medical staff.

Thank you

 

[hkgordon89]

Is there a logical and rational reason for all of these late signatures? Best practices include signing off your medical note preferably the day of the service/visit, or as soon as possible. If I was to audit a note that wasn't signed off until weeks or even months later, I would question the validity of the note. If late signatures is a habitual thing by your providers, I would get your Compliance Officer involved and develop a strategy/policy to shield your providers and practice from further compliance issues.

Thanks for the advice. There is no “real” reason I can put my finger on. It seems to either be “It was a busy clinic day, then I had to go to the hospital and then I forgot” or “Oops I thought I signed it”.
I have office visits stacking up because the notes are unsigned and then once they are they're signed so late it makes me uncomfortable to bill them.