Provider Resources

Friendly Reminder: Use Legal Names!

Written by HealthTeam Advantage | Jul 24, 2024 2:36:26 PM

We understand that over time your patients become more comfortable with their physician, and this should be the goal. However, while it is great to have that rapport, it is necessary that the medical record remain a legal document. This requires the patient’s legal name as stated on their insurance card as well as the correct date of birth, month, day, and full year.

When a record has been requested for any type of audit, it will be rejected if any of the above information does not match the insurance paperwork exactly. John cannot be Johnny or Jack or Jon. Randall cannot be Randy. Susan cannot be Sue or Susie. While you can and should address your patients as they prefer, please use only the legal name on the record.

Using nicknames or being one number off on a date of birth or year immediately flags the record as unacceptable for any audit, and all the great documentation is simply unacceptable.

Please refer to the Office of the National Coordinator’s (ONC) list of best practices for data capture by data attribute.

References

ONC. (2024). Best Practices for Data Capture by Data Attribute. Retrieved from HealthIT.gov: https://www.healthit.gov/playbook/registrar/chapter-3/