The signature process for anesthesiologist documentation is a bit trickier than some might think, according to a new blog post from founder and CEO of MiraMed Global and president and CEO of Anesthesia Business Consultants, Tony Mira.
When anesthesiologists sign medical documents, they are ensuring that all of the information is true and correct. For many providers, Medicare has several rules in place surrounding the signature process.
First, all medical records involved must be signed by the anesthesiologist. This includes progress notes, round notes, lab reports, critical care notes and more.
Second, medical records can only be signed by the anesthesia practitioner on the case and connected to the records. Having additional staff sign this documentation, even a medical scribe on the case, can render it invalid.
All providers who directly worked on the case must sign the documents, however. That includes the teaching anesthesia provider, the initiating provider and the medically directed CRNA.
Third, while Medicare says that signatures can either be handwritten or electronic, you have to ensure that the electronic signature is specifically deemed acceptable by the medical facility.
Fourth, signatures must contain a provider's full last name, and at least one letter from the first name. The post also recommends adding your credential as well. Additionally, Medicare emphasizes that the signature must be legible or it will not be accepted.