Medical Record Signatures
The enhanced ability to enable physicians to sign medical records electronically is highly efficient. However, along with this new time saver, 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. Records finalized in this manner are not signed.
BWH Medical Record general documentation guidelines require that clinicians “Authenticate by signing (via computer key or pen) any verbal or telephone order within 24 hours” and to “Authenticate (“sign”) each entry and include the professional title and clinician identification number. The guidelines also include the following: “Notice to Physicians: Medicare payment to hospitals is based in part on principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the patient’s attending physician by virtue of his or her signature in the medical record.”
Medicare advises us through their local Carrier that “The rendering/performing provider’s signature must be present and legible within the medical records for each occasion of service.”
JCAHO requires that hospitals have a system in place to assure that only authorized individuals make entries into medical records; to identify the date and author of every entry in the medical record; and to enable the author to authenticate an entry to verify it is complete, accurate, and final. Authors are required to authenticate those entries as required by hospital policy, medical staff bylaws, Federal and State laws.
LMR users must take the following steps to review, edit and sign notes in the LMR Document Management queue.
1. After opening the LMR, click the Desktop dropdown and then open the Document Management module
2. Click the subject of the note that you want to finalize. Clicking on the subject of the note will bring you into the actual text of the note.
3. Make any necessary edits accordingly.
4. Click the final/next button located at the bottom of the screen to move onto the next note to be finalized. If just finalizing that individual note, click the finalize checkbox at the top left-hand side of the screen and then click OK at the bottom left-hand side of the screen.
5. The user will then be required to sign any changes that were made.
6. Proceed to the Sign tab (which will be illuminated in red text) to authenticate your changes. **Your password will be the same password you use to log-on to the Partners network**
If You Have Questions:
If You Have Any questions regarding the process for reviewing, editing and finalizing notes in LMR, please contact Allison Benoit at abenoit@partners.org; Jackie Raymond, director, Health Information Services at ext. 2-6068; Georgette Wilson at ext. 2-5599; or Neil Walsh at 617-732-9377.