Nicknames/shortened names in medical records

Messages
1
Best answers
0
I have notice an increasing use of nicknames and shortened names in medical records at our facility. I advised practitioners to use full legal names in medical records as the records are subject to subpoena, names need to match insurance information, etc. I got a lot of pushback. People wanted to use "Will" instead of "William" but others were not even close. Using legal names was just a given at all the other facilities where I have worked. I was looking online for information to show support for this, but was not able to find anything definitive. Am I totally off base here? Do other facilities use nicknames in medical records? I feel like it just looks bad/unprofessional if nothing else. I would welcome opinions, example, policies, etc. Thanks!
 

CatchTheWind

Guest
Messages
649
Location
Boca Raton, FL
Best answers
0
We always use the name that matches the Medicare or insurance card to ensure that claims aren't rejected for a non-matching name, and that any records sent will have the same name as on the claim.
 

chimilej

Guest
Messages
10
Best answers
0
I was always under the impression the medical record should match the insurance card. When I came across a shortened name recently, I asked if the medical record information should be changed. I was told it was just "best practice" to have the names match. It did take me a few minutes to find the record I needed, because the name did not match, so its definitely not the most efficient process to have. I didn't look any further for a specific policy/ regulation though.
 

hblakeman

Networker
Messages
70
Best answers
0
EHR Names

We enter patients into our EHR based off of their DL or State ID. Our EHR has a place to put "Nicknames/Prefers to be called". Also, in the insurance box, there is an area to put "Insurance Card Name Override" if the legal name is different from what the insurance company has in their system -this is the name that will go on the claims.
 
Top