CMS SOM App. M, Tag L679

All entries must be legible, clear, complete, and appropriately authenticated and

dated in accordance with hospice policy and currently accepted standards of

practice.

Interpretive Guidelines §418.104(b)

A hospice may create its own policy on authentication of clinical records based on

accepted standards of practice. Hospices must follow State laws regarding authentication

of clinical records, and, within this context, alter their policies as often as necessary to

adapt to changing technologies and practices.

Medicare requires a legible identifier for services provided/ordered. This method must

be handwritten (not stamped) or an electronic signature to sign an order or other clinical

record documentation. The noted exception is that facsimiles of original written or

electronic signatures are acceptable for the certifications of terminal illness for hospice.

Stamped signatures are not acceptable.

Providers and physicians using electronic signatures should recognize that there is a

potential for misuse or abuse with alternate signature methods. For example, providers

need a system and software products that are protected against modification, etc., and

should apply administrative procedures that are adequate and correspond to recognized

standards and laws. The individual whose name is on the alternate signature method as

well as the provider bear the responsibility for the authenticity of the information to

which they have attested. Physicians should check with their attorneys and malpractice

insurers in regard to the use of alternative signature methods.

Hospices may not accept stamped physician signatures on orders, treatments, or

other documents that are a part of the patient’s clinical record.

Surveyors must have access to clinical records. If the record is maintained electronically,

the hospice must provide all equipment necessary to read the record in its entirety. The

hospice must also produce a paper copy of the record, if requested by the surveyor.

All State licensure and State practice regulations continue to apply to Medicare-approved

hospices. Where State law is more restrictive than Medicare, the hospice needs to apply

the State law standard.