In the 43 years and roughly 11 months that I’ve walked the planet, there have been a number of hoaxes that have been identified after careful study. From Clifford Irving’s “autobiography” of Howard Hughes to the Tassadai Tribe to the Hitler diaries to Balloon Boy, there is no shortage of things in our culture that appear authentic on first blush that turn out to be nothing more than elaborate inventions.

Being a natural cynic and skeptic, when these frauds rear their head, I begin to expand the thought model and wonder about accepted interpretations of long-standing monuments of human existence. What if Stonehenge was just some crazy person’s attempt at modern housing gone terribly wrong? What if the Inca roads were actually an ancient horse race track? What if the Egyptian hieroglyphics that have been interpreted by historians as blessings to the god Ra actually translate to “Thursday: Ate eggs. Worshipped the cat. It was hot again in the desert”.

As a medical chart auditor, when confronted with the average physician’s handwriting, it is easy to fall back into this pattern of thought. Thankfully, I also carry with me the curse of horrible penmanship, so I’m uniquely suited to look at handwritten physician documentation. Sadly, as of yesterday, that skill set may not be enough.

Beginning March 18th, CMS brought forth signature requirements for physician documentation that are much more stringent than in the past. These rules stemmed partially from a sudden sharp increase in the Comprehensive Error Rate Testing (CERT) error rate in 2009, with missing or illegible signatures on medical record documentation being one of the main drivers of the error rate spike.  

Aside from a mass reintroduction of the Palmer Method to the physician community, there are definitive ways to get the physician signature recognized as legitimate on documentation.

Let’s begin with the premise that the physician has an illegible signature. If the physician utilizes a record that is pre-printed with his or her full name and credentials, identifying the physician of record can be as easy as circling the physician’s name on the record and providing a signature on the same page. If the provider provides an illegible signature over his or her typed or printed name, this is also acceptable. In the absence of records pre-printed with the physician’s name, the last method of identifying an illegible physician signature is through the use of a signature log, which would contain the provider’s printed name and credentials along with the physician’s signature.

A legible signature can take the form of either the full first and last name of the physician, or the physician’s first initial and full last name. It is not recommended that an initial be used in place of the physician’s last name unless the physician’s name is pre-printed on the medical record or is accompanied by a signature log, as in the examples above.

If the physician neglects to sign a portion of a handwritten note, but the note page contains other entries in the same handwriting that are signed, the documentation is considered acceptable.

A signature stamp, or the words “Signature on File” without a corresponding physician signature are not considered acceptable documentation of the physician’s signature.

While the annals of history have provided us with multiple interpretations of the same landmarks or events, audits of physician documentation by CMS and their contracted entities are not nearly as open-minded or forgiving. While many interpretations can be reasonably argued, a lack of a signature that clearly identifies the physician of record presents an unnecessary risk of a negative audit finding to a physician. Following the steps outlined above offer the shortest root to the beginnings of a defensible medical record.

10:08 am, March 19th, 2010 |