Most of us who’ve been around healthcare know that physician handwriting is hieroglyphic, at best. However, nurses and other professionals aren’t far behind. Maybe it’s our keyboard-oriented world, but handwriting is getting worse every day. Keeping in mind that medical records are legal documents that have patient care and payment implications, it behooves us to make sure the information is legible and identifiable.
A common deficiency surfacing these days has to do with signatures. More often than not, signatures are illegible and may not even contain a professional designation. Urge your staff to make sure to sign legibly and if this is a recurring difficulty, consider investing in stamps that bear the person’s name. If you’re a clinician and you know your signature looks like chicken scratch, it might be a good idea to have your own handy stamp. Please note that the stamp does not take the place of the signature. It just translates it to the rest of the world.
Missing professional designations is inexcusable, really. No ifs, ands or buts: no matter where you sign your name in a chart, it MUST contain the initials that go with your profession. In the world of deficiencies, this one is needless, and easy to fix. Just think of your student loans every time you sign your name. If that doesn’t remind you to add your title, we don’t know what else to say.
Final note: a Master List of Signatures should be a requirement in your organization. This document can be a single page per employee or a running log. The idea is to have every individual who documents in your patient files to give a sample of his/her best signature and initials. Store this document separately from the employee file and keep it indefinitely. Imagine ‘participating’ in a lawsuit where you need to identify someone’s chicken scratch in one of your agency’s records… and the person’s employee file has been destroyed. I rest my case! (pun intended)