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Physician delegates to sign off their charts notes

  1. Default 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


  2. #2
    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.

  3. #3
    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.
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  4. #4
    Quote Originally Posted by CatchTheWind View Post
    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

    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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