Do providers need to sign and date dictated and transcribed patient office practice progress notes?
Provider medical record documentation is used by all disciplines to plan and assure appropriate patient care. MMIC’s recommendation of signed and dated validation of dictated note content is based on National Standards of safe medical care and documentation. The Center for Medicare and Medicaid Services (CMS) condition of participation 482.25 reads, “All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished.” The American Health Information Management Association (AHIMA) and the Joint Commission Standards (IM 6.10) in the 2008 standards mimic the CMS condition of participation statement. The statement, “Dictated but not read” is a RED flag for all plaintiff attorneys, calling attention to a patient care note that may be incorrect. Documentation of Case Law findings notes settlement of cases due to inaccurate or missing medical re
