Note when you discuss results with the patient. Don't leave blank spaces on the page. Adding entries at a later time is unacceptable unless accurately dated. Don't leave yourself open to accusations of doctoring the records. Entries must be signed.
Initials are acceptable, but signature is preferable.
Don't sign for someone else. Records must be written in ink. Go ahead and invest in a pen, it's a business expense. Pencils are fine in 2nd grade, but not for documentation. Record normal findings as well as abnormal.