HIPAA regulations stipulate that medical records be signed off within three business days of the date of service. Unsigned medical records can be accessed, edited, or deleted by anyone with access to our EHR and thus put the security of our patients’ PHI at risk. In addition, other vital functions cannot be performed. For example, we are unable to:
- Send any records back to referring doctors that referred a patient to us
- Send any records to accompany a consultation request that we send out
- Send any records to attorneys
- Bill any insurance for services rendered
Missing signatures also create voluminous amounts of additional work for the medical records and billing staff. They have to search for, track, and communicate with attendings about each and every missing signature. Therefore, it is of vital importance for attendings to do the following on every patient encounter:
- Log into each of your intern’s exams from the consult room or exam room during the patient encounter.
- Get in the practice of signing off on your charts at the end of each clinic session. Double check to make sure you don’t have any outstanding charts by running a missing signature report before leaving for the end of the day.
If additional information needs to be added to a record at the end of the clinic session, sign off on the record and input the additional information later with an addendum explaining why the chart was reopened after signoff.