How should I sign my nursing documentation in a client’s health record?
Documentation in a client’s health record begins with date and time and ends with the recorder’s signature and designation. At minimum, the expectation is for you to sign your nursing documentation with your signature and your designation of LPN, RN or NP.
If you possess more than one nursing designation, you should sign your documentation with the designation in which you are working during that shift. For example, if you hold both an LPN and RN license, and you are working the shift as an RN, you should sign your documentation “Jane Doe, RN”.
Nurse practitioners are required to hold both an RN and NP license. To decrease the possibility of confusion for clients and other members of the health care team, NPs should sign their documentation with “NP”.
Personal initials can only be used if a master list matching your initials with your signature and designation is maintained in the client’s health record. Signatures and initials must be identifiable and follow specific agency policy.
If you wish to sign your documentation with a specialty certification you have obtained, you must ensure the certification is from an established certification program, for example the CNA Certification Program. NSCN only authorizes the use of titles, signatures or abbreviations obtained from established certification programs. You must sign your nursing designation first, followed by your specialized credential, for example: “John Doe, RN CON(c)”