What documents must the doctor sign?
- Updated:
- December 2019
- Topic:
- Admin/Record Keeping/Charting
Three questions often come up from both team members and doctors: What documents must the doctor sign? What can a team member sign? What documents need no signature at all?
The answer to all three questions, in general, is that the doctor must sign everything that relates to the clinical treatment of the patient, as well as most other administrative areas of the practice. Ultimately the doctor’s license is on the line and at risk when the documentation standards established by state regulation are not met.
Health History
A team member can review the health history, and, when trained correctly, may alert the doctor to any abnormalities, conditions, or medications of importance. That team member should co-sign the health history. The doctor should review the patient's health history, making a note of any existing conditions that could affect, or be affected by, the intended treatment. However, the doctor has the ultimate responsibility of following up with the patient, ensuring the proper documentation, and modifying treatment as dictated by the patient's condition and the doctor should sign or co-sign the health history.
Informed Consent
The doctor and patient should sign all informed consent forms before services are provided. Signed consent forms indicate that the patient has been informed and understands the risks and benefits of the treatment, and has been given the opportunity to have all questions answered. A team member may review the informed consent information with the patient and prepare any questions for the doctor to answer prior to that signature.
Treatment Plan
The doctor should co-sign the treatment plan with the patient. The patient’s signature indicates that they have been made aware of their existing conditions and that the doctor has explained the proposed treatment plan.
Clinical and Hygiene Notes
The doctor should sign all the clinical notes, including the hygiene notes. The hygienist and the doctor should both sign the hygiene note, except in those states where a hygienist can directly diagnose and produce a full evaluation. If the hygienist can diagnose, the doctor would not have to sign that note. If a clinical team member records the clinical information, both that team member and the doctor should sign the clinical record.
Insurance Claims
All insurance claims are signed by the treating doctor either directly or electronically before their submission. A team member may be permitted to sign on the doctor’s behalf. However, be aware that the doctor is responsible for the accuracy of that claim form even if the team member has the right to sign the claim.
Prescriptions
The doctor should sign all prescriptions sent to pharmacies and dental labs.
Other Documents
Other than medical or dental claims, the doctor would not have to sign certain business documents that do not directly affect the clinical treatment. Examples of these documents may include but are not limited to financial arrangements, missed or canceled appointment information, and insurance demographic information.
How Are the Records Signed?
Records can be signed in several ways. Most practice management software utilizes electronic signature pads that affix a signature to various documents. The practice can also adopt document signature protocols. For example, the full name of the doctor who reviewed the document is typed in the designated place on the document. That full typed name signifies that the doctor has reviewed the documents and has affixed their full name in lieu of a signature.
