Purpose

This policy establishes standards and procedures for creating, applying, validating, auditing, and retaining electronic signatures and related authentication in LifeCare’s EMR to meet Medicare (CMS) documentation and payment requirements for outpatient rehabilitation therapy services. It applies to all therapy records and any orders, plans of care, encounter notes, progress reports, certifications/recertifications, discharge notes, and communications stored or referenced by the EMR

Scope

This policy applies to all licensed Physical Therapists (PT), Occupational Therapists (OT), Speech Language Pathologists (SLP), therapy assistants, and any other authorized personnel who may create, review, or authenticate clinical documentation within the EMR.

Definitions

Electronic Signature: A secure, unique, and verifiable electronic method of signing documentation that identifies the individual signer and indicates their approval of the content.

Authentication: The process by which the signer verifies they authored, reviewed, and approved the content. For EMRs, authentication requires a secured computer entry with a unique identifier of the primary author and date/time

EMR System: The electronic medical record platform used by LifeCare Therapy Services for all clinical documentation and recordkeeping (Clinicient InsightGO).

Legally Acceptable Signature: A signature that meets CMS, Medicare Program Integrity Manual, and Florida state requirements for identity verification, date/time stamping, and traceability.

Governing Standards  

1. All clinical entries must be legible, complete, dated, and authenticated by the person responsible for the service or evaluation, in written or electronic form.

2. Medicare requires identifiable, signed, and dated documentation to support coverage/payment; claims may be denied for missing/illegible/unauthenticated signatures.  

3. Electronic signatures are acceptable when they are unique to the user, secured, time‑stamped, and indicate the signer’s identity/intent (e.g., “Electronically signed by Jane Doe, PT, 02/16/2026).

4. Stamped signatures are not accepted except for documented disability under the Rehabilitation Act of 1973.  

5. Attestations and signature logs may cure missing/illegible signatures in many cases; however, a missing signature on an order generally cannot be cured by attestation (the order is disregarded).

Policy

1. Electronic signatures are the primary method of authentication for all therapy documentation.

2. Each clinician is assigned a unique EMR login and self-generated password. Credentials cannot be shared and are tied to the individual's login.

3. Electronic signatures have automatic association to the signed documentation and must include: the clinician’s full name, professional credentials (e.g., PT, OT, PTA, COTA, SLP) and are date/time stamped.

4. Unsigned or incomplete documentation is not considered valid for clinical, regulatory, or billing purposes. The EMR system generates reports identifying unsigned notes, which are reviewed regularly. 

5. Unalterable audit trails are automatically maintained by the EMR system  

Corrections/Amendments

Corrections or amendments must follow CMS compliant standards.

• Original entry remains visible

• The addendum is dated, signed, and time-stamped

• There is no deletion or overwriting of original documentation

Authentication of Orders or Certifications

When a physician or non-physician practitioner's signature is required, the EMR stores the signed order or certification as an attachment to the patient's record.  Unsigned orders are not valid.