Medical Records – Signatures, Amendments and Delayed Entries
Completing Your Documentation According to Guidelines
The Centers for Medicare and Medicaid Services (CMS) has established guidelines for compliant medical record documentation. Specifically, CMS states that “All medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided…”
We all know what legible is, but how is complete defined? CMS elaborates that “A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment and services; document the course and results of care, treatment and services; and promote continuity of care among providers.” And, of course, the record must be dated and signed by the author, whether in written or electronic form. CMS states that service “should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”
CMS further writes that “services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered”, but acknowledges that certain entries may need to be amended, corrected, or entered after the service was rendered. This is an acceptable practice for unusual delays, as long as the amendment is documented according to the guidelines. No information can be deleted or removed from the medical record. With paper medical records, a single line strike through of the erroneous information would still allow the original content to be readable; the author must sign and date the revision. The electronic medical record will identify any amendment, correction or delayed entry and require that the author re-sign electronically with a date and time stamp.
And, as you are well aware, “Medical necessity of a service is the overarching criterion for payment.” Ensure that your medical record is complete and compliant, and supports the service you are billing, prior to submission.
Sources: CMS Pub. 100-07, Transmittal 47, §482.24(c)(1); CMS Pub. 100-04, Transmittal 178, Sec 30.6.1; Medicare Integrity Program Manual, Sec 3.3.2.5;
For additional information, access this CMS Fact Sheet about Signature Requirements: