JRSM > Volume 96, Number 1 > Pp. 51

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Anonymized dysgraphia

Andrew Thompson Koshy Jacob   Jamie Fulton

Derriford Hospital, Plymouth, UK

Dr Rodríguez-Vera and colleagues (November 2002, JRSM¹) found that a substantial proportion of clinical records were unclear because of poor handwriting. In the UK, the General Medical Council says that doctors must keep clear, accurate, legible and contemporaneous patient records which report the decisions made and keep colleagues well informed when sharing the care of patients². Good communication between colleagues requires sufficient note-taking as well as legible handwriting. We conducted a survey of the post-take ward round entries in the case notes of 100 patients at Derriford Hospital, Plymouth. We studied the communication in the notes between the admitting team and the doctors who ultimately look after the patients. In 42% of cases the presumed diagnosis (following a consultant's review) was not recorded. Despite a management plan being recorded in 89% of the notes, in 43% there was room for doubt as to whether investigations had been requested or merely proposed. These communication failures were compounded by the fact that in 53% of the records the doctor's name was either illegible or not documented, so that the doctor could not be contacted to clarify the management plan.

It is the responsibility of the doctor to write clear and accurate patient records, something that will not be solved by electronic patient records alone.

REFERENCES

1. Rodríguez-Vera FJ, Marín Y, Sánchez A, Borrachero C, Pujol, E. Illegible handwriting in medical records. J R Soc Med 2002;95:545 -6[Abstract/Free Full Text]

2. General Medical Council. Good Medical Practice, 3rd edn. London: GMC, 2001

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This Article 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 Thompson, A. Articles by Fulton, J. Search for Related Content PubMed PubMed Citation Social Bookmarking                      What's this?