All entries into a patient's medical record should be signed by the physician or other person making the entry. Ideally, the signature will contain the rendering physician or other clinician's first and last names and credentials (MD, DO, NP, PA, RN, etc.) and the date of the service. The signature serves as authentication of services rendered or ordered.
Increasing efforts in the payer community to find and reduce the number of payments made in error are resulting in more requests for medical records. It is important to note that the absence of a legible signature of the physician or other clinician who provided a billable service may result in denial and recoupment of previously paid benefits.
Signature Requirements
Signature stamps are not acceptable for authenticating records
Signature stamps are not acceptable for Medicare and Medicaid claims. Many private payers will also not consider a stamped signature as authentication of who delivered a service.
