Best Practice Regarding Signing of Medical Records

Recently, WPS Medicare received the following questions when requesting documentation to support a billed Medicare service:
1) "Can I just go ahead and have the physician sign the order now, since he or she forgot to sign it"?
2) "Can I have him/her sign the progress notes and fax them to you"?

The best practice is to have the physician sign the medical records at the time the order or progress notes is written. Once a review contractor has received documentation for review, any additions to the medical record could be deemed as falsifying a medical record.

Page Last Updated: Thursday, 15-Dec-2011 14:34:19 CST