Do You Have a Compliant Electronic Health Record Documentation and Signature Process?

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At least once a week, this author receives questions about signature compliance in electronic health records (EHRs). Some physicians, qualified healthcare professionals (QHPs), and hospital owned outpatient wound/ulcer management provider-based departments (PBDs) seem to think they can circumvent facility and Medicare signature requirements just because an EHR can be programmed to do so. Before taking signature shortcuts, providers should review all the facility signature policies/procedures and the wealth of signature guidelines that have been released by the Centers for Medicare and Medicaid Services (CMS)^1,2 and the Medicare Administrative Contractor (MAC) that processes the provider’s claims. If the answer is still not clear, providers should discuss the issue with their legal counsel and/or their liability insurer. Because appropriate signatures are nearly always a part of pre- and post-payment audits, providers should remember that their identification appears on every claim.
 
Because 4 signature scenarios/questions continue to be submitted from physicians, QHPs, and PBDs throughout the country, this author decided to pose the 4 scenarios/questions 1) in an interview with Donna Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, a consultant who has a wealth of experience performing wound/ulcer management medical record reviews, and 2) to one of the MACs. Below you will find Donna’s answers followed by a recap of the MAC’s responses.
 
Kathleen: Welcome, Donna! Thank you for agreeing to share your expertise with the readers. I know that you conduct medical record reviews for many providers. I understand that your audits determine if 1) the documentation supports medical necessity and 2) if the medical record includes all the documentation elements (including appropriate signatures) required for coverage and payment, and to support the codes reported on claims. Let us begin with the first scenario and question about signature compliance. After you provide your answer to each scenario/question, I will share the MAC’s answer with you and the readers.

Scenario 1 and Question

The electronic health record (EHR) that the PBD uses has an optional feature that would allow the physicians and QHPs to “sign all unsigned charts.” If the feature is enabled, the physicians/QHPs could sign all the outstanding medical records without reviewing them. Because the physicians/QHPs tend to have many unsigned charts, the PBD believes this option should be enabled so their claims could be processed quicker.
 
Should the PBD enable the “sign all unsigned charts” feature?   
 
Donna: Thank you for inviting me to be interviewed about this very important topic. The first scenario and question is an excellent way to begin the interview. The PBD, physicians, and QHPs must follow the hospital’s authentication of medical records policies and procedures, which are always based on state laws, Joint Commission requirements, and medical staff bylaws. I doubt if the “sign all unsigned charts” option would align with most of these requirements.
 
In addition, if I were a physician/QHP, I would be very concerned if my patients’ medical records could be signed without my review. Kathleen, as you mentioned in your introduction, the physician/QHP is ultimately responsible for the documentation in the medical record. Although the “sign all unsigned charts” option could be a quick way to close the medical records for billing purposes, and/or to remove the physician from the “suspension for surgery list” due to delinquent medical records, physicians/QHPs should be concerned about their liability if they sign any medical record without first reviewing it. In fact, I doubt if physicians/QHPs would sign a contract without reviewing it. Patients’ medical records have as much, if not more liability attached to them. In fact, if a PBD enables this EHR option, I recommend that physicians/QHPs request that it be disabled.
 
MAC: The MAC reminded the physicians/QHPs that their signatures verify that all the information in the medical record is accurate. If the physicians/QHPs sign medical records without reading them, the medical records may contain errors for which they may be held liable. Before this EHR signature option is enabled, the physicians, QHPs, and PBDs should discuss the process with their legal counsel and their liability insurer.
 
Kathleen: Donna, thank you for your explanation and recommendation. You and the MAC definitely align with your answers. Now let us discuss the second scenario and question.

Scenario 2 and Question

The EHR used in the PBD has an optional feature that allows two clinicians to document in the same medical record at the same time. For PBDs with disorganized workflows, this feature could seem useful. However, if both clinicians are documenting in the same area of the medical record, the documentation of the last clinician overrides/changes any documentation entered by the first clinician. This feature could be described as “last one done, wins.”
 
Should the PBD enable this feature?
 
Donna: In my opinion, this optional EHR feature could lead to conflicting documentation from 2 clinicians. In most cases, the attending physician/QHP drives the diagnoses for the case. Therefore, the “last one done” should not be able to override/change anything in the medical record, unless the “last one done” is the attending physician/QHP. In other words, the attending physician/QHP should always have the final say on the documentation and should be the only one able to override documentation if others documented incorrectly. Remember that conflicting documentation will confuse both coders and auditors!
 
The EHR administrative policies and procedures should outline these documentation and signature permissions, and the EHR should be set up according to these permissions. If any of the permissions are unclear, these concerns should be discussed with the facility’s Medical Records Committee, with the medical staff office, and/or with the director of the health information department.  
 
MAC: The “last one done, wins” appears to be a flaw in the EHR. Each clinician’s documentation should be captured. Before this feature is enabled, you should discuss its ramifications with legal counsel or with your liability insurer.
 
Kathleen: Thanks, Donna. Once again, you and the MAC align in your answers. I especially like your suggestion to speak with the Medical Records Committee, the medical staff office, and/or the director of the health information department before enabling that EHR option.
 
Now let us move to the third scenario and question.

Scenario 3 and Questions

On Monday, the physician and the PBD nurse both signed the medical record of a patient who received an application of a cellular and/or tissue-based product (CTP) for skin wounds to a clean ulcer on the foot. On Tuesday, the nurse remembered that she did not document the measurements or the description of the ulcer to which the CTP was applied. Because the charges had not yet been dropped, adding to her documentation was a simple matter of un-signing the chart. However, the nurse’s additional documentation conflicted with the physician’s medical record documentation that the foot ulcer was clean. The nurse documented that the ulcer was about 50% covered with slough, had exposed tendon and some green drainage.
 
Should the nurse be able to make these additions/changes to the documentation without the physician’s knowledge? Should the physician who applied the CTP be required to un-sign the medical record to allow the nurse to change her documentation? Should the physician be required to review the nurse's documentation, to ensure that their documentation is not in conflict, and then to re-sign the medical record?
 
Donna: As I mentioned in a previous scenario, the physician’s name is on the claim that is submitted to the payer. Therefore, after the PBD nurse’s additional documentation is added, the physician should review the medical record, amend it if needed, and then sign it. Physicians/QHPs often forget that if medical record documentation is missing or conflicting, that they are held responsible for the quality and accuracy of the documentation, especially if an audit is performed.
 
MAC: The nurse must make an amendment to the medical record if she is changing the physician’s notes. The physician should be notified to review the amended medical record, to document agreement with the nurses’ documentation or to amend the physician’s documentation, and then to sign the medical record.
 
Kathleen: Donna, thank you once again. Now let us address the fourth common issue, which first states the PBD’s policy, then describes the scenario, and ends with several excellent questions.

Scenario 4 and Questions

A PBD’s policy states that charges will drop 72 hours after the medical record is signed. Within that 72-hour window, clinicians can un-sign the medical record, make any changes or additions to the original documentation, and simply re-sign it. After 72 hours, the medical record will be locked and the charges will be dropped. If any changes must be made to the medical record after it is locked, the changes must be made as an “addendum or correction,” but will not generate entirely new documents.
 
On Monday at 1 pm, the physician and the PBD nurse signed the medical record. On Thursday at 1 pm, the chart was locked and the charges for the encounter were dropped. On Friday, the nurse remembered that she forgot to document the application of a multilayer compression bandage. The nurse contacted the EHR vendor and requested that they unlock the medical record so that she could document the compression procedure which she performed.
 
The EHR vendor knows the PBD policy and also knows that if they violate policy and unlock the medical record, another claim for different services will drop, 72 hours later, for the same encounter.
 
Should the EHR vendor open the medical record to allow documentation changes after the charges have dropped, or should the nurse be told to follow the PBD policy and make an addendum to the medical record? Also, should the physician be informed about the change to the medical record?
 
Donna: Most PBDs drop bills between 24 hours and 72 hours. If there is a significant documentation error in the medical record, an addendum is required. The system should be able to rebill if the charges and/or the claim are not correct. Of course, it is best to correctly document the first time! However, in situations where the billed codes caused an overpayment or an underpayment, it is usually worth rebilling. The coders and billers should be able to assist with the rebilling. Always remember that during an audit, a printout of the medical record is mandatory and should document the medical necessity of the encounter and should support the code(s) billed.
 
MAC: After the medical record is signed, the nurse should change her documentation via an amendment.
 
Kathleen: Donna, thank you for sharing your documentation expertise with the readers. I was happy to see that you and the MAC agreed on your responses to the scenarios and questions, which have provided clear directions about compliant documentation and signature processes.
 
In summary, readers should keep in mind that if they are not confident about their documentation and/or signature processes, they should discuss specific scenarios and questions with their legal counsel and/or their liability insurer. In addition, readers should also read the excellent article entitled “How Does Your Electronic Record Measure Up Under Audit?” that Donna authored in this issue of Today’s Wound Clinic. 
 
Kathleen D. Schaum is a founding member of the Today’s Wound Clinic editorial advisory board and oversees a consulting business. She can be reached for consultation and questions by emailing kathleendschaum@gmail.com.

References
 
1. CMS Program Integrity Manual. Chapter 3. Section 3.3.2.4. Medicare Program Integrity Manual. Last accessed March 14, 2023.
2. MLN Fact Sheet. Complying with Medicare Signature Requirements. Last accessed March 14, 2023.