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.)

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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