Forum - Questions & Answers
alteration to medical records signature requirements
Hello,
Does anyone know if there is any documentation preferably from gov't stating that if a Dr already signs a note and a nurse goes in after and adds something like "patient discharged @ 3pm" that the Dr has to re-sign the note to authenticate it???
re: alteration to medical records signature requirements
The closest I could find was this: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf
The relevant part is on page 41042, which suggests that the author of the alteration sign and date the alteration (or that in the EHR it can be tracked to the nurse who made the change).
That doesn't suggest the physician has to do it, though it is not a bad practice.