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Add countersignature Short Medical History

welcome to this tutorial on signature requirements medical record entries the information given in this training is correct as of august 2020 the most current information related to this topic can be found on the meridian and cms websites at the links listed on this slide per the internet only manual or iom scribes are not providers of items or services when a scribe is used by a provider in documenting medical record entries cms does not require the scribe to sign and date the documentation the signature of the treating physician or non-physician practitioner or npp on a note indicates that the physician or mpp affirms the note adequately documents the care provided reviewers are only required to look for the signature and date of the treating physician or npp on the note they won't deny claims for items or services because ascribe has not signed and dated the note refer to change request 10076 on our meridian website under medical review signature requirements and scribes for more information to be in compliance with the conditions of participation and receive proper accreditation all signatures need to be dated and timed documentation must contain enough information to determine the date on which the service was performed or ordered if the entry immediately above or below an entry is dated medical review may reasonably assume the date of entry in question cms provides an example in the iom the claim selected for review is for a hospital visit on october 4th the documentation is one page from the hospital medical record containing three entries the first entry is dated october 4th and is a physical therapy note the second entry is a physician note that is undated the third entry is a nursing note dated october 4th the reviewer should conclude that the physician visit was conducted on october 4th all services provided to beneficiaries are expected to be documented in the medical records at the time they are rendered occasionally certain entries are not properly documented and will need to be amended corrected or entered after rendering the service health record documents submitted containing amendments corrections or addenda must clearly and permanently be identified as such indicate the date and author of the entry and identify all original content without deletion listed here are the instructions on how to amend correct or identify delayed entries in the paper medical record use a single strikethrough the original content make the amendment addition or correction the author of the altered records must sign and date the entry that was made and the author may use their initials for this correction provided there's evidence of who the provider is when correcting electronic health records entries must provide a reliable means to identify the original content the modified content and the date and authorship of each modification of the record a provider cannot add late signatures to medical records beyond the short delay that occurs during the transcription process medicare does not accept retroactive...