A new change request from CMS makes clear that doctors may initial and date amendments and delayed entries into medical documentation. Before doctors only had the option of signing and dating the information, but now they could either sign or initial.
Change Request 9332 was posted Oct. 2. Its implementation date is Nov. 2.
Contractors have previously encountered situations where a physician’s amendment to a record was invalid because the physician initialed it rather than signing it, the request states. Due to the change, initials would be acceptable “if the medical record contains evidence associating the provider’s initials with their name.”