Legal requirements for your initials in the chart

Nurses General Nursing

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Specializes in Rehab, Infection, LTC.

I work with a nurse that literally only uses one initial. Her name is Sue Jones (made up name of course) and she signs all of the MARS/TARS, etc. with only "S".

When the medical records coordinator complained to the DON, the DON backed the nurse when the nurse said there is not a guideline to how many initials you must use in the chart so she can use one if she wants.

Does anyone know the guideline for using initials? I've googled my tail off but can't find "the rules". All I find is where to use initials, not how many.

This is driving me nuts as I know there are guidelines somewhere.

Anyone have any ideas?

Are you this nurse's manager? That's the only reason I can imagine that something that doesn't involve you would drive you nuts.

Anyplace I've ever worked, any time you use your initials to sign something off, there's a place somewhere on the same sheet/form where you sign with your full name to indicate which initials mean which nurse. As long as one can identify somewhere on the form that "S" is Sue Jones, RN, it doesn't really matter. You could use an "X" or a star, or whatever, as long as someone reviewing the chart can identify that that symbol = Sue Jones, RN. Even "SJ" doesn't mean anything without the accompanying "real" signature -- the hospital probably has several "SJ"s employed there. Nobody's initials mean anything, by themselves, without the accompanying full signature.

I also wonder why this would be the OP's concern. Are you somehow directly involved?

Specializes in Telemetry, Case Management.

For a long time at one job, I was the only person in the building with the initial "K", and I signed off my mars/tars as "K". When they hired another K, then I had to go to "K+(last initial)".

Specializes in Rehab, Infection, LTC.
Are you this nurse's manager? That's the only reason I can imagine that something that doesn't involve you would drive you nuts.

as a matter of fact, miss donthaveareplytothequestion, i AM her manager.

As long as she signs her full name next to the initial in the space for identifying the initials with signatures and titles, she has complied. I don't see what the problem is.

Specializes in Rehab, Infection, LTC.
As long as she signs her full name next to the initial in the space for identifying the initials with signatures and titles, she has complied. I don't see what the problem is.

thats why i am asking, i dont know if there IS a problem. i thought we legally had to use our initials, both of them or all of them if sharing the same initials with someone. if not, no problem but i thought we legally did. this is something i disagree with and as her manager, wanted to show the DON the legalities if there is any. if not, i'll tell her i was wrong and she was right.

I would advise you to call your state Board to inquire, but my state Board does not even respond to the public so I don't know what good that would do in your case.

as a matter of fact, miss donthaveareplytothequestion, i AM her manager.
1) Not sure what the "miss" part means.

2) as the manager, I would hope you would know the legality of any issue before you charged anyone under you with any wrong doing.

Specializes in Rehab, Infection, LTC.
1) Not sure what the "miss" part means.

2) as the manager, I would hope you would know the legality of any issue before you charged anyone under you with any wrong doing.

and what does this look like to you? a post to hear myself type? reread the OP, i am asking if anyone has any idea of the legalities as I cant find them.

Specializes in Rehab, Infection, LTC.
I would advise you to call your state Board to inquire, but my state Board does not even respond to the public so I don't know what good that would do in your case.

haha, i dont think ours responds to the public either. but that did make me wonder, maybe CMS has some guidelines that would address this.

and what does this look like to you? a post to hear myself type? reread the OP, i am asking if anyone has any idea of the legalities as I cant find them.

LOL

I love nursing management.

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