Legibility and The Medical Record

Have you ever wondered why a physician writes in such a manner that really no one on earth can read it? Over the years I have worked with more physicians then I have hair on my head and the one constant I find is the illegibility of physician handwriting. Not sure what this stems from, maybe a fear of if they are sued they can make the documentation say whatever they want. Honestly though I have run into situations where other physicians cannot even decipher what one of their peers has written. This leads to trouble in a wide range of areas.

It is important to understand that the patient's medical record serves many purposes, which include:

Collection of clinical data for research and education

Illegible records can also lead to medical errors. This is where it becomes a demand placed on physicians to ensure their documentation is written in such a manner so that in the event a patient claims they were injured by the physician, the physician's documentation provides clear understanding to all that was provided the patient and what if anything the provider can grasp onto, to protect his or herself. Many times patients who are provided a dosage of medication are given the wrong amount because of the inability to read the physician handwriting. This is especially common in the inpatient hospital setting. This happens because many nurses are afraid to approach a physician with regard to their handwriting, so a guess is made and more often than not it spells disaster for the patient, the hospital, the physician and the nurse. Now, those of you who work in the hospital inpatient setting are going to say there are standards to which the physicians are held for legibility. Sure there are but are they really always held to those standards? Especially those who are big earners for the hospital! All of this could be avoided through some simple steps that we will talk about in just a bit.
As I was doing my research for this article I came across a legal case in a Texas where a physician was found responsible for the death of a patient because of bad handwriting. So, what can your physicians do in an attempt to alleviate the problems of bad handwriting? Well here are some suggestions for you to chew on, dictation, EMR or Templates. Each comes with its own set of issues to work through but they are ways to ensure patient safety, which is and should be the practices first concern.
Issues with handwriting are not just brought up by consultants and physician staff. Groups such as CMS, OIG, DOJ and many others have for years raised concerns regarding physician's illegible handwriting. As a matter of fact JCAHO (Joint Commission on Accreditation of Healthcare Organizations) has two standards that address legibility, IM.7.10 and MS.8.2.3. 
If your providers shrug off your arguments about patient safety, which I am sure they will not you can also raise an issue for them that directly affect their wallets. Keep in mind Medicare states that documentation supporting a billable service must be readable or it is considered a non-billable service.  Other groups such as The AMA warn healthcare providers about the association between illegible writing and medical errors.
For years I have performed audits of medical providers documentation for both billing and quality purposes. Many times when I have been unable to read what a provider has written I will take it to that individual and ask them to read it to me so I can score it for them. There have been literally hundreds of times the provider has said to me I am so embarrassed, I am not sure what it says. How scary is that; A physician who cannot even read their own handwriting.
Keep in mind the way it is done with CMS and other groups who audit your practices, typically if an auditor cannot decipher what has been written they will send it to another auditor for review, if they are not able to read the handwriting it is assessed as an overpayment or non-billable services. JACHO also has a way of determining if a provider's handwriting is legible or not.  Many times a surveyor will have the health professional who is expected to carry out the patient order try and read the documentation. 
Bad handwriting is no laughing matter it is something your providers need to take very seriously. With all of the technological advances and the tools that are at your provider's fingertips there is no reason for legibility to ever be an issue.
Sean M. Weiss is a Senior Partner with The CMC Group in Atlanta, Georgia. The CMC Group is a full scale national and international medical consulting and legal research firm. The CMC Group is also a full Coding and Compliance tools and resources Bookstore carrying more than 1000 products from Decision Health, the AMA, INGENIX, PMIC, MAG, Contexo/MMI and The CMC Group. To reach Sean directly contact him at Sean.Weiss@thecmcgroup.net or you can visit them online at www.thecmcgroup.net  or www.thecmcbookstore.net

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