Make Sure Your Medical Records Are Legible
Illegible patient records pose a risk to patient care, drain healthcare resources, jeopardize optimal reimbursement, and carry potential legal ramifications. Specifically:
- Illegible medical records can lead to misunderstanding and patient injury.
- The patient record is the most important evidence when defending a malpractice claim and, without a legible medical record, defense efforts may be weak.
- The time and talent of clinicians could be better spent delivering patient care than clarifying illegible entries.
Tips to ensure your records are legible include:
- Make a conscious effort to write clearly. The simple act of sitting down while writing should improve legibility.
- Dictate your notes. Although more costly, dictation will improve readability and has the added benefits of increasing reimbursement and decreasing staff time handling documentation issues.
- Institute an electronic medical record system.
- Use preprinted encounter sheets, which can be checked or circled. (Just be careful to avoid the pitfall of not providing enough documentation when using these forms.)