Submitting Unsigned Documentation

Physicians and providers should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead may make use of the signature authentication process.

Authentication of an unsigned medical record entry may be provided through an attestation statement. The statement should begin with clear identification of the patient and then should include the information included in the following example taken from CMS Transmittal #327:

“I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., M.D.]___ when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

CMS has directed that reviewers shall NOT consider attestation statements from someone other than the author of the medical record entry in question (even in cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements).

While you are looking at signatures on medical records, you might notice that the record itself is not clearly legible. To be sure that the documentation can be used to support your charges, it is acceptable to have the record transcribed exactly as originally noted. This transcribed record should be annotated as a transcribed copy of the record and signed by the physician or clinician with the current date. The information from the original record should not be altered or added to unless specifically noted below the transcribed record as an addendum or correction.