Top Four Attorney Concerns About Medical Records Part 1: Reading Handwriting in Written Medical Records
According to a poll run by Pat Iyer, the top four attorney concerns about medical records were reading the handwriting on manually written medical records, the lack of uniformity of charting systems, knowing whether certified copies are complete, and that the electronic medical records provide little insight.
Poor Handwriting
Reading handwriting in written medical records has been a longstanding problem for practicing medical professionals.
Especially for nurses or pharmacists trying to take an order from a hospital chart, or trying to guess what medication a prescription is for or the dose prescribed. This issue has been at the center of countless medical errors both in and out of the hospital. It has led to the development of hospital policies disallowing certain abbreviations and requiring a zero be placed before a decimal in a milligram or microgram dose of medication to name a few.
It was also felt that the electronic medical record would be the solution to the illegibility problem, however, unfortunately, that solution came with its own set of problems. (I will address this issue in a subsequent post).
Unfortunately, even though these policies were implemented records still exist where the unapproved abbreviations exist. While this posed a problem for nurses, it poses an even greater problem for a lawyer trying to read and interpret these records. A lawyer doesn’t have any medical training and is unaware of common abbreviations. The poor lawyer hardly stands a chance of reading the writing and interpreting its meaning.
The risk to the lawyer is he or she may miss a critical issue in the case due to this lack of insight.
Who Wrote This Entry?
Difficulty deciphering handwriting is further complicated by difficulty ascertaining who the author is because of a scribbled signature. Once the author is ascertained, the lawyer may try and clarify the meaning in a deposition. Unfortunately, however, I have seen instances where the medical provider themselves claims to be unable to read their own handwriting. Whether this is true or not is up for debate. If it is a critical element of the case that could carry meaning that will either make or break a case for negligence, the provider’s inability to decipher their own handwriting would be to their advantage.
Help is Available
This is where having a medical consultant review the records prior to a deposition would be helpful.
The medical professional can make an educated guess based on the contents of the record where the questionable information is located, and the document itself as a whole. The medical consultant would know to compare the writing in an order to the orders placed with the pharmacy, and then ultimately the medication dispensed to a patient. If there is a medication error, either dosage or the actual medication itself, the medical consultant would be able to recognize this error.
The busy attorney can try and do this himself, however, it can be very time consuming when you are unfamiliar with medical records, medical abbreviations, medical terminology, and don’t know what you are looking at or where to look. If you find yourself in this situation, give me a call. I can help you sort through the murky record and gain some clarity as to what is happening in your case.
If you are having issues dealing with medical records and need assistance organizing and deciphering what is going on, Med Legal Pro is your solution!
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Tracy Liberatore JD, PA
