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Signature for H&P?

  1. Question Signature for H&P?
    Medical Coding Books
    I need help!

    I need to find documentation that spells out that a physician needs to sign a form written H&P. This H&P is the form used in the room with the patient which the physician then uses to dictate a typed version (which he signs).

    I feel silly asking help with this, but I honestly haven't been able to find anything yet. Anyone know where this ruling exists?

  2. #2
    Location
    NCF Gainesville
    Posts
    64
    Default
    I would look for the regulation that states all hospital documentation (including orders, notes, etc) have to be dated, times, and stamped. That is of course if they want to use it towards their H and P as a billable service.
    Jeni Smith, CPC, CPMA

  3. #3
    Default
    Quote Originally Posted by hmlyme View Post
    I need help!

    I need to find documentation that spells out that a physician needs to sign a form written H&P. This H&P is the form used in the room with the patient which the physician then uses to dictate a typed version (which he signs).

    I feel silly asking help with this, but I honestly haven't been able to find anything yet. Anyone know where this ruling exists?

    Have you tried the CMS website? If not, try there. Put in documentation signature requirements and it should search the entire sight for reference articles.

  4. #4
    Default CMS Signature Requirements
    References:
    U.S. Code of Federal Regulations Title 42 Pubic Health-Conditions for Medicare Payment
    http://ecfr.gpoaccess.gov/cgi/t/text....1.2.24.2.52.9


    Department of Health and Human Services
    The Case of Samuel Nigro, M.D.
    http://www.hhs.gov/dab/macdecision/Nigro.html
    Brian R. Boyce, CPC, CPC-I

    Healthcare Operations, Regulatory Compliance & Coding Consultant

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