Physician delegates to sign off their charts notes

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I need help!

Since our physicians are so busy they suggested that we assign delegates to sign off their charts notes. The CMS guidelines for signature requirements does not really mentioned delegates, is this even legal to assign someone to sign off their chart notes? I do not really agree with their suggestions but if there are guidelines out there that I do not know please share them with me.

Thank you in advance

Josephine
 

CatchTheWind

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No one can sign the provider's notes except the provider himself.

I would think the reason it's not in the guidelines is because it is so obvious that it doesn't even need to be included.
 

Pathos

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Your gut instinct is correct. Besides being unethical, a provider can get in big trouble if they sign off someone else's note (except for Incident-To rules, which is a different scenario).

I read about a provider who didn't finish several medical notes before they left their practice. The practice had to write each and single one of the unsigned notes off for this exact reason. Even the Chief Medical Officer couldn't legally touch these notes.
 

CodingKing

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I would think the reason it's not in the guidelines is because it is so obvious that it doesn't even need to be included.

That's always the problem, some think that because its not mentioned that its up to interpretation. They don't understand that just because it doesn't say you cant do something that it automatically mean that you can.
It can be easily inferred that signature means you are attesting that the information in the record is correct. That's impossible to do if you were not present.

Even though it doesnt mention delegates, its pretty clear


https://www.cms.gov/Outreach-and-Ed...gnature_requirements_fact_sheet_icn905364.pdf


How does CMS define a handwritten signature?
A mark or sign by the ordering or prescribing physician or NPP on a document signifying knowledge,approval, acceptance, or obligation.

What if I use a scribe when documenting medical record entries?
Regardless of who writes a medical record entry, you must sign the entry to authenticate it adequatelydocuments the care you provided or ordered. It is unnecessary to document who transcribed the entry.

It seems clear only the person who actually provided the service can sign off on it.
 
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What if the office staff chooses the wrong rendering provider when entering the patients demographics who's name then prints on the claim form but is not the rendering provider who actually signed off on the notes? Would those claims have to be refiled as a corrected claim?
 

Orthocoderpgu

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You may want to remind your doctors who want to "off load" authentication of the note to someone else that the documentation is a legal document after its signed or otherwise authenticated. Right or wrong they are then legally responsible for everything in that documentation! Lawsuits happen, even when you don't expect them. Does the provider really want to admit in court that they were not authenticating their own notes and don't want to be held responsible for its content?
 

csperoni

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If you billed incorrectly under the wrong provider initially (for whatever reason), then yes, you should refile a corrected claim.
 
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