Policy on Signature Requirement for Behavioral Health Documents

Ensuring Compliance, Accountability, and Documentation Integrity

Purpose

The purpose of this policy is to establish clear and mandatory requirements for signatures on all behavioral health documentation in order to ensure accuracy, authenticity, and compliance with the regulatory standards governing behavioral health services in Maryland. This policy protects the integrity of the clinical record, strengthens accountability, and ensures adherence to HIPAA, the Maryland Department of Health Behavioral Health Administration (BHA), Maryland Medicaid regulations, and all applicable federal and state documentation laws. Proper signature practices support quality clinical care, facilitate accurate billing, and ensure that records remain defensible in audits and legal proceedings.

Scope

This policy applies to all employees, contractors, interns, trainees, supervisors, administrative staff, and any individuals responsible for creating, reviewing, or maintaining behavioral health documentation within Lartey Wellness Group. It covers all written and electronic records generated during the provision of mental health services and requires consistent adherence by all personnel involved in the clinical workflow.

Policy Statement

All documents that form part of a client’s official behavioral health record must be properly completed, signed, dated, and authenticated by the responsible provider. A document without a valid signature is considered incomplete and cannot be used for clinical, billing, legal, or audit purposes. This includes all clinical assessments, evaluations, treatment plans, progress notes, crisis documentation, discharge summaries, consent forms, and all correspondence prepared on behalf of the client. In accordance with Maryland Medicaid and BHA regulations, documentation is invalid and non-billable without the required signatures, and failure to comply may result in denial of claims, recoupment, or regulatory action.

Document Preparation

All behavioral health documentation must be completed promptly, accurately, and clearly. Providers must use the organization’s approved electronic health record system or, when needed, approved paper forms. Documentation must reflect the services provided and adhere to Maryland Medicaid, BHA, and professional standards. Incomplete, delayed, or improperly prepared records jeopardize clinical care, compliance, and reimbursement. Providers are responsible for ensuring that all documentation meets the standards required by Maryland law and organizational expectations.

Signature Requirements

All documentation must contain a valid signature from the provider who authored the record, including their full legal name, credentials, date, and time. Electronic signatures must comply with HIPAA and state authentication standards. When documentation is completed by an intern, trainee, or unlicensed clinician, a licensed supervising provider must review, approve, and co-sign in accordance with Maryland supervision laws. Documents requiring client or guardian participation, such as consents or treatment plans, must include their signatures unless a legally appropriate reason is documented. If a client is unable or unwilling to sign, the provider must explain the reason in the record and confirm that the information was reviewed with the client.

Timeliness Requirements

Signatures must be completed as soon as documentation is finalized and always within the regulatory timeframes set by Maryland Medicaid, BHA, and internal organizational policy. Treatment plans and related documents must be signed before implementation. Progress notes must be signed on the same day that the service is provided, unless a clinically justifiable reason is documented. Delayed or missing signatures can result in compliance issues, gaps in care, and payment denials.

Corrections and Amendments

Signed documentation cannot be deleted, altered, or overwritten. If a correction is needed, the provider must create an addendum that explains the reason for the amendment, provides the corrected information, and includes a new signature with the date and time. The original entry must remain intact and visible. Maryland regulations require transparency in all clinical records, and improper alteration of documentation is strictly prohibited.

Record Retention

All signed documentation must be stored securely in the client’s official record in accordance with HIPAA, Maryland COMAR regulations, Maryland Medicaid documentation rules, and the organization’s internal record retention schedule. Records must remain accessible for internal quality assurance reviews, state audits, federal audits, and compliance reviews. Both electronic and physical signatures must be preserved for the full retention period required by law.

Compliance and Enforcement

Failure to comply with this policy may result in corrective action, retraining, performance review, suspension of clinical duties, or termination of employment depending on the nature of the violation. Missing, delayed, or invalid signatures can lead to Medicaid payment denials, recoupment of paid claims, and negative audit findings. All staff members have an individual responsibility to ensure that their documentation complies with state law and organizational standards. Adherence to this policy is essential for maintaining quality of care and protecting the organization from legal and financial risk.

References

This policy is guided by the HIPAA Privacy and Security Rules, Maryland Health-General Article, COMAR regulations governing Outpatient Mental Health Clinics, Maryland Medicaid Provider Manuals, Behavioral Health Administration requirements, CMS documentation standards, and Lartey Wellness Group internal policies. Professional ethical guidelines, including those issued by NASW, APA, NBCC, and relevant Maryland licensing boards, inform the expectations contained in this policy.

Review and Revision

This policy will be reviewed annually or sooner if changes in law, regulation, payer standards, or organizational needs require revision. The organization reserves the right to update or modify this policy at any time to ensure ongoing compliance with Maryland requirements and industry best practices.

Conclusion

The accuracy and integrity of behavioral health documentation depend on consistent and proper use of signatures. This policy ensures that all staff members understand their responsibility to complete, sign, and maintain clinical records in a timely and compliant manner. Adhering to these requirements not only protects clients and supports safe, effective care but also preserves the organization’s compliance standing with Maryland Medicaid, regulatory agencies, and accrediting bodies. By following this policy, staff contribute to a transparent, accountable, and legally sound clinical environment that upholds the highest standards of professional practice.