LNCtips.com: Deciphering Bad Handwriting
To those unfamiliar with medical records, review of documentation can be a challenge. Medical records include many abbreviations and medical terminology composed of Latin and Greek terms. Some abbreviations, such as PT and DC, have more than one meaning. Not much attention is paid to punctuation and grammar in medical records and spelling errors can make them difficult to read. Legal nurse consultants play a pivotal role not only in translating medical records but in identifying their legal significance, including standards of care, causation and damages. But even LNCs can have trouble interpreting records when the handwritten documentation is illegible
As nurses, we've all had to deal with physicians and others who have really bad handwriting. In a clinical situation, the nurse can speak with the physician to ask for clarification of, say, orders that are illegible. It's not as easy once a lawsuit is being contemplated or has been filed. In-house and independent LNCs may not be able to informally clarify records with treaters depending on the circumstances of the case and whether the LNCs are working for the plaintiff or defense. To maintain their objectivity, expert LNCs never speak with non-client treaters.
Deciphering horrible handwriting from medical records is a skill that many legal nurse consultants learn through trial and error. This discussion focuses on physician handwriting but the principles apply to other types of health care providers as well. Here are some tips to help new LNCs who are trying to figure out illegible handwriting.
Use your judgment deciding how much time to spend deciphering bad handwriting. All medical records are important but some are more so than others. For example, it may not be worth it to agonize over 10 year old podiatry records for treatment of toenail fungus for a patient who died unexpectedly from a ruptured abdominal aortic aneurysm. On the other hand, records from the primary care provider and cardiologist would be very important in this situation.
Invest in a good magnifying glass. Working with copies of medical record copies can be challenging and a magnifying glass may really help. When working with electronic medical records, use the magnifier on your PDF reader to blow up hard-to-read sections.
Review typed reports such as consults, discharge documents, and histories and physicals first. Consults and discharge documents usually give the name and specialty of consulting physicians and their plan of care. Sometimes there are both handwritten and typed consults from the same physician. Comparing the typed report to the handwritten one can give clues to illegible words in the handwritten report.
If you have trouble reading the physician's signature, check the nursing notes. Nurses will sometimes chart the names of physicians who have seen the patient.
Physicians' orders may be more legible than their progress notes or progress notes may be more legible than orders. Comparing the orders to the progress notes, especially the plan of care, often can help the LNC identify specific words.
Consider the context of the note. For example, pulmonologists discuss respiratory issues so look for words and abbreviations used by the particular specialty such as DOE, SOB, dyspnea, ABGs, etc. Flipping to the nursing notes for the same time period may also give you clues to what the physician's note entails.
Find a clearly written letter, such as a "P" and then find other words that contain that letter. You can often piece together various words that way. Once you have identified a word. you can use the other letters in that word to expand your comparison. For example, if you identified "Protonix" you can try to find other words that contain R, O, T, N, I, and X as well as P.
It may help to try to interpret all the bad handwriter's notes in one sitting. Sometimes you'll be able to read words in a later note which will enable you to understand earlier notes.
Conversely, it may help to let the task of deciphering sit for a day or two if possible. Sometimes words that eluded you earlier will pop out at you after a few days.
Use the process of "fresh eyes." If you have access to another legal nurse consultant, ask her or him to view the problematic handwriting and give you suggestions.
Even using these principles, there may still be some illegible documents or portions of documents that you will be unable to interpret. When this occurs, tell the attorney about the indecipherable notes and the potential significance of the notes. The attorney can then decide to depose the treater or get a transcript of the treater's notes, depending on the circumstances and specifics of the case.