Health Information Management

Q&A: What are the risks associated with providers only initializing orders?

APCs Insider, October 16, 2015

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Q: We are having a difficult time getting our practitioners to sign their orders. We have a hybrid record and when they have to actually sign their name, they want to take a shortcut and use their initials. Then, they don’t want to fill out the line on the signature log so we can associate the initials to them. Does this mean that all of those orders with only initials will be ignored if we have an audit?

A: It is always best practice for the practitioner to authenticate an order with their full signature, and not just because CMS or auditing entities want it that way. It is best practice for the physician and the patient for all entries and signatures in the record to be complete, including a full signature. However, it is also true that practitioners must authenticate and sign a huge number of record entries every day.

 

As far as Medicare records are concerned, CMS published Transmittal 615 on October 2. In this transmittal, CMS notes that contractors are consistently seeing that physician amendments to a record are not valid because the physician initialed rather than signed the entry. Under the Medicare Program Integrity Manual requirements, a full signature is required. This transmittal documents that contractors shall accept initials as confirmation for amended and delayed entries in the medical record.

When CMS uses the word “shall,” that means that it is a requirement. Please take not that this states specifically that this applies to “confirmation for amended and delayed entries in the medical records.” It does not state that all physician signatures may be initials only. That does not meet the requirement in the Program Integrity Manual.

The actual requirement and instruction from the transmittal states:

The contractors shall accept confirmation of amendments for delayed entries to paper records that are initialed and dated, if the medical record contains evidence associating the provider’s initials with their name.

It is key to note that there must be a physician signature in the medical record (which must meet the legibility, signature log, etc., requirements) in order for the initials to be valid. Each facility will need to insure that they audit records where there are initials to ensure that there is a valid signature in the same encounter of the medical record for correlation. The medical record for the individual encounter must support the signatures and initials for that specific encounter as that is what the contractors and other audit entities will be using to support the services rendered and billed.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

 



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