When documenting, what names should be used?

Using full legal names and titles when documenting is essential for clarity and professionalism. This practice ensures that all records are unambiguous, accurately identifying the individuals involved in care or treatment. It is particularly important in healthcare settings where precise documentation can affect patient safety, communication amongst healthcare teams, and adherence to legal standards.

Utilizing full legal names reduces the likelihood of errors and misunderstandings that can arise from similar first or last names or the use of nicknames, which may not be legally recognized. It also helps in maintaining a consistent protocol that can be vital in legal contexts, where accurate records are necessary for compliance with regulations and policies.

By documenting with full legal names and titles, healthcare professionals also demonstrate respect for patients and colleagues, fostering a professional environment that supports effective communication and accountability.