JRSM > Volume 95, Number 11 > Pp. 545-546

This Article Abstract Full Text (PDF) Send a Quick Comment Alert me when this article is cited Alert me when Quick Comments are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rodríguez-Vera, F J. Articles by Pujol, E Search for Related Content PubMed PubMed Citation Social Bookmarking                      What's this?

Illegible handwriting in medical records

F Javier Rodríguez-Vera MD   Y Marín MD   A Sánchez MD   C Borrachero MD     E Pujol MD  

Internal Medicine Department, Hospital Juan Ramón Jiménez de Huelva, Huelva, Spain

Correspondence to: F Javier Rodríguez-Vera, C/Arjona No 12 Esc 2 1°A, 41001 Sevilla, Spain E-mail: frodriguezv{at}sego.es

	SUMMARY

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
In 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.

	INTRODUCTION

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
Despite the computer revolution, much information in clinical records continues to be handwritten. The originator may understand what has been written, but difficulties can arise when other parties are involved. Only a few studies, however, have been reported on the legibility of medical documents and these largely about prescriptions^{1,2,3,4,5,6,7}. We therefore decided to examine the legibility of case histories written on admission of patients to our hospital.

	METHODS

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
The hospital, located in south-west Spain, has 600 beds. We obtained a representative sample by examining, on a single day, case notes from patients whose rooms had even numbers. Certain specialties—intensive care, haematology, gynaecology, paediatrics—had their own record systems and were excluded. The ‘clinical history’ was taken to be any document written by a clinician that included the patient's name, age, medical condition, and reason for admission. Two medical residents, recently arrived at the hospital and not involved in the admissions or recording of case notes, evaluated the legibility of the document on a score of 1-4. This classification (Box 1) has been used by others⁵. They went through a training process in order to reach a kappa concordance coefficient of 0.85. A third reviewer adjudicated in case of disagreement.

Box 1 Legibility scoring Illegible (most or all words impossible to identify) Most words illegible; meaning of the whole unclear Some words illegible, but report can be understood by a clinician Legible (all words clear)

 

	RESULTS

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
117 case notes were examined and 18 (15%) were scored 1 or 2—i.e. they were so illegible that the meaning was unclear. Table 1, giving results for individual specialties, indicates that surgical departments performed worse than medical departments.

View this table: [in this window] [in a new window]   Table 1. Scores for individual departments

 

	DISCUSSION

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 
A weakness of this study was that it might have been skewed by the poor handwriting of just a few clinicians who were responsible for many admissions. Also, we did not distinguish between cold admissions, in which the notes might simply consist of a shorthand reminder of the outpatient consultation, and acute admissions, where a full and comprehensible history is more important. This might partly explain why medical departments scored better in this respect than surgical departments.

If 15% of case histories are illegible, does this matter? In principle, it is a source of avoidable error—for audit, research, and clinical communication^8,9,10. The remedy lies either in a more conscientious approach to record-keeping, with an eye to the needs of other readers, or an accelerated move towards computer-based systems¹¹. In our view, it is time to say goodbye to manuscript in medical notes, whether legible or not.

	REFERENCES

TOP SUMMARY INTRODUCTION METHODS RESULTS DISCUSSION REFERENCES

 

1. Winslow EH, Nestor VA, Davidoff SK, Thompson PG, Borum JC. Legibility and completeness of physicians' handwritten medication orders. Heart Lung1997; 26:158 -64[Medline]

2. Brodell RT, Helms SE, KrishnaRao I, Bredle DL. Prescription errors. Legibility and drug name confusion. Arch Fam Med1997; 6:296 -8[Abstract/Free Full Text]

3. Russell N, Morrison R, Johnson S, Robertson WO. Reducing errors by increasing legibility. West J Med2000; 173:163[Medline]

4. Kozak EA, Dittus RS, Smith WR, Fitzgerald JF, Langfeld CD. Deciphering the physician note. J Gen Intern Med1994; 9:52 -4[Medline]

5. Berwick DM, Winickoff DE. The truth about doctors' handwriting: a prospective study. BMJ1996; 313:1657 -8[Abstract/Free Full Text]

6. Lyons R, Payne C, McCabe M, Fielder C. Legibility of doctors' handwriting: quantitative comparative study. BMJ1998; 317:863 -4[Free Full Text]

7. Cheeseman GA, Boon N. Reputation and the legibility of doctors' handwriting in situ. Scott Med J2001; 46:79 -80[Medline]

8. Bruner A, Kasdan ML. Handwriting errors: harmful, wasteful and preventable. J Ky Med Assoc2001; 99:189 -92[Medline]

9. Hester DO. Do you see what I see? Illegible handwriting can cause patient injuries. J Ky Med Assoc2001; 99:187[Medline]

10. Brodell RT, Helms SE, KrishnaRao I, Bredle DL. Prescription errors. Legibility and drug name confusion. Arch Fam Med1997; 6:296 -8

11. Bradbury A. Computerized medical records: the need for a standard. J Am Med Rec Assoc1990; 61:25 -37

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

This article has been cited by other articles:

				D. K Sokol and S. Hettige Poor handwriting remains a significant problem in medicine J R Soc Med, December 1, 2006; 99(12): 645 - 646. [Full Text] [PDF]

				C Anton, P G Nightingale, D Adu, G Lipkin, and R E Ferner Improving prescribing using a rule based prescribing system Qual. Saf. Health Care, June 1, 2004; 13(3): 186 - 190. [Abstract] [Full Text] [PDF]

				Minerva BMJ, October 6, 2003; 327(7418): E182 - 182. [Full Text] [PDF]

				A R Panigrahi and C Cunningham Legibility and authorship of clinical notes J R Soc Med, April 1, 2003; 96(4): 208 - 208. [Full Text] [PDF]

				O M P Jolobe Illegible handwriting in medical records J R Soc Med, January 1, 2003; 96(1): 51 - 51. [Full Text] [PDF]

				A. Thompson, K. Jacob, and J. Fulton Anonymized dysgraphia J R Soc Med, January 1, 2003; 96(1): 51 - 51. [Full Text] [PDF]

				Minerva BMJ, November 16, 2002; 325(7373): 1182 - 1182. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Send a Quick Comment Alert me when this article is cited Alert me when Quick Comments are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rodríguez-Vera, F J. Articles by Pujol, E Search for Related Content PubMed PubMed Citation Social Bookmarking                      What's this?