Medical records signature guidelines
Complying with Medicare Signature Requirements MLN Fact Sheet Page 4 of 5 ICN May 2018 Do my signatures need to be dated? Documentation must contain enough information to determine the date when the service was performed or ordered. If the entries immediately above and below an undated entry are dated, medical reviewLegal Medical Record Standards Policy No. 9420. LEGAL MEDICAL RECORD STANDARDS. PURPOSE. To establish guidelines for the contents, maintenance, and confidentiality of patient Medical Records that meet the requirements set forth in federal and State laws and regulations, and to in lieu of a medical staff members signature, medical records signature guidelines
Medicare Signature Requirements. The purpose of a practitioners signature in patients medical records, operative reports, orders, test findings, etc. , is to demonstrate the services have been accurately and fully documented, reviewed and authenticated.