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Following up on yesterday’s post, I thought it would be worth giving you the full text of the policy statement on electronic signatures.  (The hyperlinks are added by me).

TO: Executive Directors of Voluntary Provider Agencies
DDSO Directors
Provider Association Directors
DDSO QM Liaisons

FROM: Sheila McBain
Deputy Commissioner, Division of Quality Management

SUBJECT: OMRDD Policy Statement on Electronic Signatures and Records

DATE: December 21, 2009

Suggested Distribution:

All Executive Directors/DDSO Directors and Senior Staff
All Quality Management staff
All Program Directors
All Voluntary Agency Medicaid and Corporate Compliance Officers and Staff

OMRDD Policy Statement on Electronic Records

The Office of Mental Retardation and Developmental Disabilities (OMRDD) accepts the use of electronic signatures and electronic records for all OMRDD documents except where a written signature or document is expressly required by law and in a manner fully consistent with the attached audit directive number 21 from the NYS Department of Health dated November 1, 2005.

An increasing number of Medicaid providers are seeking to use electronic documentation applicable to all Medicaid providers to support their Medicaid claims and to record the care, services and supplies that have been provided. OMRDD is providing these guidelines for the use of electronic signatures in the Medicaid program. These guidelines permit, but do not require, the use of electronic signatures and electronic records, and are intended for all OMRDD Medicaid providers.

As detailed in the attached directive, use of an electronic signature has the same validity as a signature affixed by hand and OMRDD auditors are instructed to accept documentation containing electronic signatures. However, providers must be prepared to authenticate or prove that the record was electronically signed by the person authorized to sign the record. An exception to this rule would apply where the applicable statute or regulation specifically requires a hand-written signature. The provider’s electronic medical record must have control features, such as pass codes, for electronic signatures.

Electronic records that reflect actual services provided and that conform to all service-specific requirements will be acceptable documentation for Medicaid purposes, subject to the review and audit by OMRDD or any other state or federal audit authority. Electronic records must be as accessible for auditing as would paper records, original or otherwise, and be capable of reproduction in paper form. For audit purposes there is an expectation, which may be supported by certification, that the paper reproduction is an exact copy of the electronic record. The electronic medical record must have a control feature which date stamps each entry into the record that cannot be turned off or over-written. The attached letter from the Office of Medicaid Inspector General can also be referenced for further policy clarification.

If you have any questions about whether your current system meet these guidelines (my understanding is that there are other systems in use which do not), please get in touch so we can discuss.

Things to consider are:

  • Can you or your staff make direct changes to the database?
  • Are all changes made to a document time, date, and author stamped?
  • Is all access to each document logged?
  • Will your documentation/software provider make direct changes to the data if you ask?

If you chose Therap, then the answers to these questions mean that you have electronic documentation that meets New York standards.  If you didn’t choose Therap, you probably don’t.

:: Justin ::

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