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Residents must be seen by a physician once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.

Physician visits are considered timely if they occur no later than 10 days after the required date.

In confirming its position, CMS specifically states: “For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author.

The method used shall be a handwritten or an electronic signature.

As the Director of the HIM department, you have been asked to work with the physician Chairperson of the Health Information Committee to make a recommendation regarding a policy on authentication, dating and timing of physician orders, including verbal, telephone, electronic, and handwritten orders.

The policy you develop must allow the hospital to be in compliance with the documentation requirements of the Joint Commission, CMS Conditions of Participation and the State Licensing regulations.

Section 483.40, the federal standard specifically pertaining to physician services, specifies that each resident must have an attending physician and a backup physician when that attending physician cannot be reached.

To encourage and implement best practice for our orders, we will be utilizing these guidelines for all payors.

CMS Conditions of Participation A-0454: All orders, including verbal orders, must be dated, timed and authenticated promptly by the ordering practitioner ...

Analysis of the Standards: CMS has the strictest policy of the three as it requires not only dating and signing but timing as well.

The facility is responsible for ensuring that each resident have an attending physician and a backup plan, and the attending physician is responsible for ongoing supervision and review of the resident’s “total program of care, including medications and treatments” at each visit.

During each visit, the physician must also sign and date progress notes and orders.