Legibility, accuracy, specificity vital in records

May 21, 2010

The increasing prevalence of electronic health records should help address the issue of illegible medical records in the future. If you write notes by hand, however, you must take the time to ensure that your medical records are legible, accurate, and specific. We share pointers to help you communicate with other healthcare professionals and create a good legal document for evidence should one be needed.

Lee J. Johnson, JD

The increasing prevalence of electronic health records should help address the issue of illegible medical records in the future. Of course, the main purpose of the record is to communicate with other healthcare professionals, and a legible record facilitates that purpose. A secondary purpose of the record, however, is to create a good legal document for evidence, and legibility also contributes toward that end.

If you are writing notes by hand, you must take the time to make your records readable to other healthcare practitioners as well as to any potential jurors. This advice seems like common sense, but examples abound of cases in which physicians did not heed it.

Take a look at the examples provided here. Ask yourself what it would be like trying to review these records if you were called in as a consultant, or what you might think if you were a juror in a case in which these records were presented as evidence.

If the doctor reads his or her own records and says that he or she ordered lab work, but the jury can't decipher the doctor's handwriting, the jurors may not believe that the doctor/defendant in a failure-to-diagnose case actually did prescribe lab work. A plaintiff's attorney might say, "So, only you and God know what the record says?"

Even worse are cases in which a doctor cannot read his or her own records. The documents are virtually useless for the defense. Similar to the aforementioned case, the plaintiff's attorney might say, "Doctor, at the time you wrote this note, only you and God knew what it said, and now only God does?"

ADDITIONAL TIPS

In addition to making sure your records are legible, here are some points to remember:

• Be accurate. Accuracy is especially important with specific medications, treatments, and numbers. A misplaced decimal point can mean a lost case. In one instance, a patient got the wrong dosage, sued, and won.

• Be specific. Specificity is crucial to other healthcare workers knowing exactly what you mean. For example, a doctor's note to "take as directed" is not specific enough. Write exactly what dosage you are prescribing.

• If you measure vital signs, record the exact vital signs. Vague entries are meaningless.

• Use only standard abbreviations. One doctor expresses pride that he fits all of his notes on one page by using his own abbreviations. What good is that medical record to other healthcare workers if they don't know the meanings of all of those abbreviations? They would need a glossary to interpret each record. One extremely damaging emergency department record read: "FLK, FDGB." What does FLK mean, funny-looking kid? Does FDGB mean fall down, go boom?

It’s difficult to know where to start reading this real-life chart example.

Remember, your records should enable you to communicate with other health professionals and also should also serve as a good legal document for evidence, if needed.

In the chart example on the left-taken from a real medical record in a real malpractice case-the doctor writes "no change in vitals" and "slightly better condition but still very critical." The account of the patient's condition is nearly incomprehensible. On the right is an example of an illegible record.

The author is a health law attorney in Mt. Kisco, New York, and a Medical Economics consultant. Malpractice Consult deals with questions on common professional liability issues. Unfortunately, we cannot offer specific legal advice. If you have a general question or a topic you'd like to see covered here, please send it to medec@advanstar.com.