Confidentiality, Privacy and Security

SIGNATURE REQUIREMENTS

  • 1.  SIGNATURE REQUIREMENTS

    Posted 09-07-2017 14:32
    Hello,
    I am trying to locate the Federal Register regulation that outlines the signature requirements for a provider and/or clinician within a patient medical record.  I thought there was one regarding how the signature should be presented (First Name Last Name, Credentials) when documenting within a patient record.  Also, for electronic signatures formatting too.  Can someone please provide me the link, if possible?
    Thank you in advance,

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    Nancy Beyer
    Senior Consultant
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  • 2.  RE: SIGNATURE REQUIREMENTS

    Posted 09-07-2017 14:40
    ​Try this its from AHIMA- Electronic Signature, Attestation, and Authorship

    http://bok.ahima.org/PdfView?oid=107152

    Hope it helps :)



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    Maria Velasquez, RHIT
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  • 3.  RE: SIGNATURE REQUIREMENTS

    Posted 09-07-2017 16:15
    Maria,
    I was actually looking at this one too.  Thank you very much.  I was able to find some additional support from this article too. I sincerely appreciate the assistance!
    Thank you,

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    Nancy Beyer
    Senior Consultant
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  • 4.  RE: SIGNATURE REQUIREMENTS

    Posted 09-07-2017 14:42
    Nancy,

    CMS has guidelines in the MLN Matters from March 16, 2010. Related CR Release date March 16, 2010. The article was updated on November 20, 2012. CR 6698 has a table that summarizes situations where signature requirements are met.

    Bonnie

    Bonnie Ormond, RHIA
    Director Health Information Management
    Carteret Health Care
    3500 Arendell Street, Morehead City, North Carolina 28557
    Office: 252-808-6529  I  Cell: 252-269-4555  I bormond@carterthealth.org







  • 5.  RE: SIGNATURE REQUIREMENTS

    Posted 09-07-2017 16:16
    Bonnie,
    This is great!  I wasn't thinking of CMS having guidelines too.  But, it makes sense.  I was also able to find where the FR is referenced with this MLN.  Thank you so much!

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    Nancy Beyer
    Senior Consultant
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  • 6.  RE: SIGNATURE REQUIREMENTS

    Posted 09-15-2017 10:49
    ​Hi,
    Recently the Dept. of Human Services (we contract with them to provide crisis stabilization services to minors) told us that our electronic signature procedure did not meet their regs.  We have clients sign their consents, tx plans, etc., with a 4 digit PIN.  They set up their own PIN and have security questions they have to answer in order to set it and then have it reset, if necessary.  The DHS stated anyone could be selecting the PIN and entering for the patient.  They would prefer for us to use signature pads which results in something that looks like an original signature on the document.
    In my opinion, signature pads are no different, anyone could sign for a patient on a signature pad.  The signatures that result from a pad typically look very little like an original signature done with pen on paper.
    Does anyone have an opinion on this subject?  Do you have any suggestions on how we can challenge the DHS on the use of PINs?
    Thank you,
    Lynn Boyes, RHIT


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    Kathryn Boyes
    Director of Medical Records
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  • 7.  RE: SIGNATURE REQUIREMENTS

    Posted 08-14-2020 11:23
    Good morning! I am on this topic and wanted to reach out to see if anyone had additional information to add since the original post.

    Does your organization require providers to enter a PIN to authenticate orders and documentation, or are their credentials for logging in to the system the administrative safeguard for authentication?

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    Ashley F.
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  • 8.  RE: SIGNATURE REQUIREMENTS

    Posted 08-14-2020 12:23
    https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf

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    Katherine Johnston, RHIT
    HIM Services Manager
    johnstonk@scheurer.org
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  • 9.  RE: SIGNATURE REQUIREMENTS

    Posted 08-17-2020 12:12
    Hi Katherine,

    I have reviewed the CMS guidelines.

    The guidelines they published for using electronic signature's are as follows: 
    ● Systems and software products must include protections against modification, and you should apply administrative safeguards that correspond to standards and laws
    ● The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the attested information
    ● Part B medications, other than controlled substances, may be ordered through a qualified e-prescribing system
    ● Medications incident to DME, other than controlled substances, may be ordered through a qualified e-prescribing system

    My question is, if the provider is logging into the EMR with their own unique username and password, does this suffice as an 'administrative safeguard'?  Currently when our providers document or enter an order, when the note is complete they click 'sign' and enter a four digit PIN.  However, entering the PIN each time has become very time consuming for our care providers, so we are trying to determine if this is absolutely necessary to meet TJC, CMS, or other regulations.

    Thank you for your feedback


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    Ashley F.
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