Illegible handwriting in medical records

Abstract

Dr Rodriguez-Vera and colleagues (November 2002, JRSM1) say that, if doctors cannot be persuaded to write legibly, the answer is computerization. This might indeed be a useful strategy for eliminating errors attributable to illegible handwriting, but the health record is beset by troubles of a more fundamental nature, requiring more imaginative solutions. Some of these arise from the fact that problem lists, action plans, and problem-oriented medical records have not been universally accepted in our medical culture, either at medical school or in so-called continuing professional development2,3,4. Without the implementation and continual updating of problem lists, drug lists (including adverse reactions), and action plans, the health record soon degenerates into a tedious litany, devoid of both structure and purpose. Furthermore, when hospital records become voluminous4 with chaotic filing thrown in for good measure (i.e. ‘anything’ filed ‘anywhere’ and ‘anyhow’) there is a formidable disincentive to attempting anything more than a cursory review of previous clinical episodes. Computerization will only make matters worse, thanks to the axiom ‘rubbish in, rubbish out’ and the limited flexibility of the present generation of healthcare computers4. Finally, since neither clinic letters nor discharge summaries are routinely audited, and in view of the reported proliferation of errors of omission and factual inaccuracies in some of the correspondence emanating from secondary care5, the electronic record might end up as a system for perpetuating misleading documentation.

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