The enhanced ability to enable physicians to sign medical records electronically is a welcomed time saver. However, along with that timesavings comes a compliance risk
Inherent in our electronic medical record keeping system is an “auto finalization” feature. This feature moves those notes that have not been approved by the author within 21 days into a “final” location and enables other treating physicians to access them.
Medicare requires physician authorization by signature before payment. In addition, our medical record documentation policy outlines physicians’ obligation to finalize by signature all medical records. Absence of physician signature has caused the hospital to refund monies to the Medicare Program as a result of a recent audit by the Office of Inspector General (OIG).
In order to avoid additional penalties and to ensure appropriate documentation for the benefit of our patients, the hospital has advised the OIG of its plan to enhance education around the signature requirement. In addition to this reminder, our compliance staff has included this topic in its ongoing training.
We have also enhanced our systems ability to identify “approved” vs. “finalized” medical records as follows: “Approved” medical records will now include the statement “electronically signed by” in addition to the typed physician name and “finalized” medical records will only display the typed physician name.
A reporting capability has also been developed to facilitate identification of physicians who do not approve their notes. We will use these reports as a catalyst to schedule individual training sessions as well as work with departmental compliance programs and the Professional Billing Compliance Committee to ensure education of physicians on these important subjects.
Call ext. 2-6068 or 2-5599 with any questions.