Forum - Questions & Answers

Sep 19th, 2014 - adamjung

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???

Sep 23rd, 2014 - CodapediaMsgBoard 96 

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.



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association