Use of Initials in Medical Documentation

WPS Medicare Carrier/FI for Iowa, Illinois, Kansas, Minnesota, Michigan, Missouri, Nebraska and Wisconsin.

Recently, WPS Medicare received the following question and statement, “Do initials satisfy Medicare’s documentation requirements? Our physician feels that providing a full “signature” to each medical record is not efficient and is time consuming.”

A valid signature (electronic or hand written) is always the best practice. Initials could be more work in the long run, depending on the type of documentation and scenario. If there are other providers with the same initials in the practice, use of initials could be confusing and call into question the identity of who actually performed the service. This could result in more uncertainty if only the first and last name initials are recorded. The question of who performed the service could be even greater if the records are hand written in an inpatient shared chart. Just like a written signature, initials must be legible. With less letters involved, it could make it very difficult to identify who performed and documented the service.

Initials could be acceptable IF the provider’s name is typed/printed on the note with their signed initials next to it. If a valid identifier is not apparent in the record, the claim may be denied or a request for a Legend/signature sample/attestation statement may be requested to identify the initials. From a legal, documentation, and Medicare reimbursement viewpoint, the best practice is use of a valid hand written or electronic signature. In some instances, initials may save time, but in many others, the additional time and resources needed to validate the initials could out weigh the saving.