Part B Physicians Must Sign Dictated Medical Records

Wisconsin Physician Services (WPS) issued guidance yesterday clarifying the importance of physician signatures on dictated notes, which emerged as a national issue identified by the Comprehensive Error Rate Testing Program (CERT). Regardless of whether dictation is given directly to a scribe, or via an electronic recording that is then transcribed, physicians must review the record and issue a signature.

The identification of the dictating physician is usually indicated on the resulting medical records, and confusion arose over whether that identification was sufficient. The guidance issued by WPS compares the transcription of an electronic record to the taking of dictation; both processes are subject to error on the part of the scribe or transcriber. Therefore, physicians must review the medical records, ensure that there are no errors, and issue a handwritten or electronic signature.

A handwritten signature should be legible, and an electronic signature must be easily identified as a valid signature affirming that the physician has completed a review.