Wiki signature/date/credentials

[AMOCERI908]

I am hearing rumblings that physician's reports need the date of dictation and must contain their credentials, i.e. M.D./D.O.. Anyone have documentation on this.

 

[RNCPC0709]

Credentials

I can't help you out on the date of dictation, but providers should always include their credentials with their signature. This is standard charting procedure. When I sign a patient chart as an RN, I always include this and was taught that not doing so is incorrect. Also, the signature, date and credentials must be legible.

Had a situation during an audit where CNA's were charting physical therapy notes when they were performing ROM activities for SNF residents. They were clearly "slopping" their signature and credential, and the provider was billing for PT.

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PB

 

[chthompson]

I think as long as your office has a signature log on file that shows the provider's COMPLETE signature (full name with credentials), AS WELL AS their "typical" signature, you should be covered in the event of an outside audit. As long as they can verify that the signature does, in fact, match up with a credentialed provider.