Wiki Who can legally sign a chart?

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StephSH

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We have a situation in one of our offices where the clerical manager is signing off on charts that have no charge attached to them.
An example of this is a child with a fracture took his cast off and wiggled his arm around and heard some popping, so mom brings him back in and has his cast re-applied. There's no charge because the original visit was billed as fracture care, so this is just follow up and free.
The MA applied the cast, and the office manager signed the electronic chart. No Dr is noted as giving an order to re-cast, no additional exam was done to see what might have caused the popping the mom reported.
Our compliance department says this is fine because there was no charge, but those of us in coding all think this is NOT OK!
We cannot find any LEGAL info online stating that a physician needs to sign the chart.

Does anyone have any legal info to support the opinion that a physican needs to sign this???
Thanks
 
1st an MA cannot be the one that "decides" the appropriate treatment is to recast. Since the child took his own cast off this need to be re evaluated by the physician. The MA can only follow physician orders from a previous encounter, since the provider did not have the opportunity to evaluate the patient post cast removal there is no encounter for the MA to follow orders from, 2nd when the MA does follow provider orders from a previous encounter, then the provider must sign this off as acknowledgement that orders were followed, it does not matter that the visit was not charged, BTW the casting could be charged even in the global. But would have had to be ordered by the provider.
I ma not certain where to tell you look for this information, however it is inappropriate for the office manager to sign anything in the medical record. She did not order it, nor assessed it, nor documented it, nor oversaw it.
What if.... the MA applied the cast incorrectly; ie too tight, too lose, the fractue had dislodged, etc... any number of issues and there is a complication down the road.. who is responsible medically?
 
All of these arguments were made by our department. We dont bill out the casting materials in most instances (we have a lot of Medicaid here, and they wont pay it, so we dont bill it out). We're still looking for some legal documentation to support our department's opinion since our Compliance and Legal departments ok'd the office staff signing the charts. I guess we can all practice medicine as long as we dont bill it! Insane....
 
If you are in NY State, check Title 10 under the Department of Health, section 405.10 Medical Records. Even though that pertains to hospitals, it does address who is allowed to authorize and sign medical record entries.

Wish that question was asked to our compliance department - I work in compliance and cringed when I read that response!
 
Who can sign a chart note?

What is required for a valid signature?
For a signature to be valid, the following criteria must be met:
• Services that are provided or ordered must be authenticated by the ordering practitioner;• Signatures are handwritten or electronic (stamped signatures are not acceptable); and
• Signatures are legible.
Reference: CMS “Medicare Program Integrity Manual� (Publication [Pub.] 100-08), Chapter 3, Section 3.3.2.4.
 
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