How to avoid problems with your anesthesia record signature: 6 insights

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There are a surprising number of rules surrounding signatures on anesthesia records. Tony Mira, founder of MiraMed's Anesthesia Business Consultants, provided tips for anesthesia providers to avoid problems with these signatures in an April 8 blog post. 

Here are six insights to remember to avoid problems in the auditing and payment process:

1. Anything deemed a medical record requires a provider signature — records such as progress notes, round notes, labor epidural records, critical care notes, consult reports, and evaluation and management reports should all be signed by the anesthesia practitioner who provided the service.

2. Pain block notes contained within the anesthesia record do not need to be signed separately if there is an indication of who performed the block.

3. Medical records should only be signed by the anesthesia practitioner who provided care in the case, not ancillary staff or a scribe on behalf of the provider. 

4. All anesthesia providers on a case must sign, including: 

  • The medically directing anesthesiologist and the medically directed certified registered nurse anesthetist or anesthesiologist assistant
  • The provider who initiated care and the provider who came in to relieve
  • The teaching anesthesia provider and the resident or student registered nurse anesthetist

5. For electronic signatures, providers must ensure that it is specifically deemed by the facility as an approved "electronic signature" and that the EMR system can capture signatures of multiple providers. Providers should also ensure the signature field and functionality align with Medicare expectations.

6. For hard-copy records, the signature must include at least the first letter of the provider's first name and full last name, per Medicare rules. The signature must also be legible to the extent where it can be matched to the name appearing on the claim form. 

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