Replies to Electronic Documents

Tara Dailey

Description

Title:

Replies to Electronic Documents

Creator:

Tara Dailey

Date:

2/3/2014

Text:

Thank you to all those who replied. I truly appreciate your responses.

Here are the replies:

1. In a typical registration There are no physical documents they sign, we have an electronic signature pad tied into the software for them to sign for a delivery receipt and for receipt of the education documents when a device is delivered, it is saved in the software and we print one hard copy of both the delivery receipt and the patient instructions and they are provided to the patient as required by law.

On registration they review all of the compliance documents that I have laminated on a ring, the registration person checks off or selects the forms they have reviewed in the software and then we ask them for them to provide an electronic signature that they have reviewed them. When they sign off you have proof they were given the opportunity to review and read the forms and we give them a hard copy if they wish( we have several packets made up in advance ready to give them if they request them) usually they don't want them. We can print them out if we want to. Everything is electronic if everything is working. If there is a problem we have a down time policy with hard copies for them to sign and later we can scan them into that appointment when the computer is back up. No paper charts other than the original RX.



2. Unfortunately, you will get 1000 responses and all will be different. There really is no answer. Medicare can (and has) at any time take a sentence out of one of their policies or manuals, interpret it to mean whatever they desire and audit us. That's what happened with prosthetics and the debacle of now needing physician notes. It's a risk and you are right to be fearful. We switched to Opie electronic records about 4-5 years ago. In my research at the time, the only place that I found where Medicare's policy stated that the original signature was required was the initial referring order (what you are likely terming the blue prescription). Just to be extra careful, we keep both the original referring order AND the we have the physician's pen & ink sign the detailed written order and we keep that. We have a single expandable file marked A-Z and keep these filed per last name.

Everything else is electronically filed. In every audit and/or request for additional info, I have sent copies of these forms & have never, in over 20 years, been asked for the original. You have to find your own line in the sand that meets your company's comfort level. Again, there isn't a correct answer here.



3. I am sure you will get many replies. We are very paperless. if fact all faxes ets are digital and not printed out and scanned in.
Now a rx you get from the doc on his paper just throw in file for 2014 from a to z. simple end of year box up and put on a shelf. This is only one small sheet of paper per patient. if they actually did come in with a rx.
Amazing how much we save in paper.
Now, one thing we still do is the fax cover that we send to the Dr. is printed out and we add hand written notes on this to make more personal. than faxed. This has a great value for us, but may look at using snagit to add the personal marks on the page.
The 2nd reason for this is the paper copy to insure they have the rx back not necessary, but it's how we still have a couple % paper in house



4. I think original signature in manual means no signature stamps like some offices have for docs. A scanned original signature should be fine.





5. I am interested in the replies to this one also. We scan all documents into the patient chart and then keep all original signed copies of forms also; so in turn, like you stated, defeats the purpose of electronic/paper less office. Thanks.



6. What you refer to as the blue prescription I am unsure of. We scan everything into our system, however we keep the following original copies for Medicare beneficiaries: Initial order (prescription), Detailed Written Order, Proof of Delivery Hope this helps



7. we have been using OPIE in a hospital setting. We primarily keep the original RX's on file and we feel fine about the EMR. It is a complete software and I have been impressed with its capabilities though the learning curve is significant. We have been audited for accreditation by ABC and we meet all Medicare standards and Medicaid standards using this software. When we became an LLC and applied for a Medicaid number we were audited for five cases, the auditor was very impressed with the software and was familiar with it. We had no problem receiving our number. We do not have any physical charts for the thousands of patients we manage, pretty amazing.


Original message:

Hello All,
I am inquiring what you or your practice's procedure is with regard to Electronic Records. We have recently switched to a new software that has scanning capabilities which we would scan all documents to the patient's file. They have said that the only original document that needs to be kept is the blue prescription. Everything else can be shredded.

As you can tell this is scaring me a little bit. I have reached out to Medicare twice and they will only refer me to the supplier manual. This is the only thing that I had found pertaining to my question- in the Supplier Standards on page 93 The documentation must be complete, accurate, and legible. Suppliers should keep original copies, not facsimiles or photocopies

That would lead me to believe that any original signed document we would still need to keep, which then almost defeats the electronic record mindset, correct?

Any help and suggestion on what you or your office maybe doing would be appreciated.

Thank you!

Tara Dailey


Tara Dailey

Armac, Inc.
Office Manager
Phone 888-422-3044 ext 211
Fax 973-328-3753
Email <Email Address Redacted> <mailto:<Email Address Redacted>>

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Citation

Tara Dailey, “Replies to Electronic Documents,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 23, 2024, https://library.drfop.org/items/show/236083.