Illegible Handwriting in Medical Records

Abstract

SUMMARYIn clinical records many items are handwritten and difficult to read. We examined clinical histories in a representative sample of case notes from a Spanish general hospital. Two independent observers assigned legibility scores, and a third adjudicated in case of disagreement. Defects of legibility such that the whole was unclear were present in 18 (15%) of 117 reports, and were particularly frequent in records from surgical departments.Through poor handwriting, much information in medical records is inaccessible to auditors, to researchers, and to other clinicians involved in the patient's care. If clinicians cannot be persuaded to write legibly, the solution must be an accelerated switch to computer-based systems.

Benefits and drawbacks of electronic health record systems

“…Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports” 7. Some of the basic benefits associated with EHRs include being able to easily access computerized records and the elimination of poor penmanship, which has historically plagued the medical chart 8,9. EHR systems can include many potential capabilities, but three particular functionalities hold great promise in improving the quality of care and reducing costs at the health care system level: clinical decision support (CDS) tools, computerized physician order entry (CPOE) systems, and health information exchange (HIE).…”

Lung sounds: how doctors draw crackles and wheeze

“…Many studies of doctors’ written entries in medical records have been retrospective,2 3 7 8 making between-doctor comparisons difficult because the originating clinical information differs between entries. We controlled the auscultation findings presented to participants in order to compare their drawings in a way not possible with retrospective analyses of different clinical encounters.…”

“…However, the content of medical records is a potential source of miscommunication between clinicians. Doctors’ written entries in medical records have been criticised for their illegibility2 3 and ambiguity 4–8. Despite the computer revolution, as well as advances in medical imaging, much clinical information in hospital records continues to be handwritten, and some of it drawn by hand.…”

The seamless transition from student to intern: from theory to practice

“…and Schneider et al 6 . suggest that doctors' writing is probably no worse than other professionals, Rodriguez‐Vera et al 7 . found 18% (3% in medical units, 32% in surgical units) of 117 reviewed charts contained illegible writing such that the meaning was unclear, yet Ved and Coupe 8 showed that audit and feedback can improve legibility.…”