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. 2002 Nov;95(11):545-6.
doi: 10.1177/014107680209501105.

Illegible handwriting in medical records

F Javier Rodríguez-Vera  1 , Y Marín, A Sánchez, C Borrachero, E Pujol
Affiliations

Illegible handwriting in medical records

F Javier Rodríguez-Vera et al. J R Soc Med. 2002 Nov.

Abstract

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.

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Comment in

  • Anonymized dysgraphia.
    Thompson A, Jacob K, Fulton J. Thompson A, et al. J R Soc Med. 2003 Jan;96(1):51. doi: 10.1177/014107680309600123. J R Soc Med. 2003. PMID: 12519809 Free PMC article. No abstract available.
  • Illegible handwriting in medical records.
    Jolobe OM. Jolobe OM. J R Soc Med. 2003 Jan;96(1):51. doi: 10.1177/014107680309600122. J R Soc Med. 2003. PMID: 12519811 Free PMC article. No abstract available.
  • Legibility and authorship of clinical notes.
    Panigrahi AR, Cunningham C. Panigrahi AR, et al. J R Soc Med. 2003 Apr;96(4):208. doi: 10.1177/014107680309600426. J R Soc Med. 2003. PMID: 12668722 Free PMC article. No abstract available.

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