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Do you use initials or full name with charting?

The practice I regularly work at uses initials (AB, RDH), but I recently temped at a practice that required your full name at the end of charting (Firstname Lastname, RDH) and their reasoning was that is what is considered legal now. I am concerned and would like to know what is legally correct so that I can follow proper rules/regulations in this profession!

Any idea where I can find this out?



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4 Answers

In my office I use my initials because im there ALL the time.. in the rare occasion that I temp, I write my full name (legible) RDH and my license number.. I do this simply for organization for that office, in case there is an issue, they know who saw that patient and there isn’t the issue of “who’s MK?”

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Places that I have Filled-in for I always would sign my full name with RDH. All the places that I’ve work at full time I only use my initials with RDH. Did not know about a law, but I’m sure that initials are fine unless you have two hygienists with same initials. If fill in hygiene you should always sign full name. It would be hard to remember who filled in at different times. If you are full time and have worked there for some time your initials should be fine since the office knows who you are and will always know….hey that was so and so who worked here for 10 years…..even after so and so has moved on. Hope this helps.

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I have always signed my first initial and last name followed by RDH. Learned in school 20 years ago, so that’s what I’ve always done. Everyone else in my office only uses initials.

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First initial and full last name RDH.

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