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Also, CMS permits the use of a rubber stamp for signature if the author has a physical disability and can provide proof to a CMS contractor of his/her inability to sign their signature due to his/her disability. All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. If so, does the physician need to authenticate the order in the record? Orders may be accepted and put in writing by personnel authorized to do so by applicable State and Federal laws and regulations. The signature log includes the provider's signature along with a typed or printed name. Typed or stamped signatures alone are not acceptable. A physician did not sign the operative report and, during the appeals process, it was denied for lack of signature. A signature added to the documentation, after the fact, is not acceptable. If a physical therapist received a provider's order with an illegible signature, but also received the written Plan of Care (POC) certified by the same provider with his/her typed name, can the POC be used as validation for the order? Since Medicare cannot accept a typed name, an attestation for the POC as well as the order is necessary. Submit final copies, not preliminary or draft copies, of documentation. Do late signatures also apply to orders for immunizations (TDAP, PPD, etc.)? It is considered valid for the signature requirement; however, the test is subject to medical necessity by the provider's intent that the clinical diagnostic test should be performed. To clarify clinical lab reports and the signature requirements, should the reports be signed by the ordering provider or the lab director? The order should be authenticated by the provider via a handwritten or electronic signature.… continue reading »
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