Here’s a quick clarification regarding documentation expectations: Typing your name into the body of your note is not required. Your electronic signature is fully compliant and sufficient for authentication.
Coders have been reminded that queries should not be issued solely because of a missing typed name. Queries are appropriate only when clarification is needed to support accurate code assignment — such as resolving a date of service discrepancy or validating clinical documentation.
This approach aligns with our Health Information Management Query Process Policy (Salem Health intranet access required for link), which follows national standards from CMS, AHIMA and ACDIS to ensure compliant and respectful query practices.
Thanks for your collaboration and commitment to high-quality documentation. If you have any questions or would like to review the policy, please contact Cassie Enderle, Director of Health Information Management.