ER medical records not being signed and dated is one of the top reasons for a bill from an ER physician to be rejected by a payer. Such a simple little thing can hold up your hard earned payment. For Electronic Medical Records (EMR) the input side works well (or not so well), but output may not have what you think it does. Usually there is some sort of “Sign” button on an EMR. This must be clicked in order to complete a chart. The EMR must have an annotation that the chart was electronically signed and must have a date stamp. Try printing out a paper copy of the EMR and see what it actually looks like. Does it have a proper electronic signature? Signatures are an issue for EMR’s but even a bigger issue for paper charts. For paper charts the signature must be legible. If your signature is not legible then you must print your name next to it. CGS (our Medicare provider for Ohio) has published lots of information about signatures on their website.
A signature alone is not sufficient, there must be a date next to the signature to prove date of the signature on both paper and EMR. Lastly, it is a good idea to make sure that somewhere on the chart your credentials are identified as “Attending Physician” or “ER Doctor”. The issue is that payers don’t know if you are a mid-level, resident physician or ER Attending.
Without taking care of these essential documentation steps, we cannot get paid for the services that we provide. This may seem nit-picky, but these are the rules and it quickly becomes very serious when you don’t get paid. Insurers don’t like this either, since they have to deny the claim, send it back to the Doctor and re-process it once it is complete. They would rather it be right the first time. If a chart is submitted for payment without a proper signature, it can be corrected, but not by just signing the chart. You have to file an attestation that you really did see the patient. CMS has made detailed attestation instructions available on their website, and the attestation form for Ohio is available for download from CGS.
This entire issue can be solved by ensuring that you sign and date a patient’s medical record with your legible name and credentials, especially if you are on some sort of paper chart.