Physicians are infamous for their sloppy handwriting. Patients and health care providers often struggle to discern what is written. Tired hands (on account of long days and lots of writing) have been blamed. Others have pointed out that, for many of us, our handwriting is not on view for the world to see (meaning physician handwriting is seen more but not necessarily messier than average).
Nonetheless, messy handwriting is a serious problem. Similarly-named medications can be confused, leading to adverse and even fatal consequences. Shorthand understood by professionals is gibberish to laypeople, who may need to follow instructions or decipher their medical records. Some sources suggest there are thousands of deaths annually because of unreadable physician writing.
Legible handwriting is not just good practice – it’s the law. Ontario’s Medicine Act states that the records required by the regulation shall be “legibly written or typewritten”.
The College of Physicians and Surgeons of Ontario (the body that regulates physicians and reviews patient complaints) has a policy on medical records stating:
The College expects that information in a medical record can be understood by other health professionals. Using conventional medical short forms is permissible. However, to reduce error, the meaning should be clear to a health professional reading the record. Physicians should not use abbreviations that are known to have more than one meaning in a clinical setting.
While exceptions exist, patients may obtain access to the information in their medical records. Although the medical record is not written primarily for the patient, physicians must be prepared to provide explanations to patients of any term,code, or abbreviation used in the medical record
When a complaint is made about a physician or health care provider, medical records are gospel. They tell us what transpired, whether consent was provided, and other pertinent information. It can be difficult to assess a complaint where legibility is an issue. In a recent case:
The Committee stated that it did not find the Applicant’s records to be satisfactory or decipherable and had difficulty following the plan of care, noting that the Committee panel included an ophthalmologist.
The Health Professions Appeal and Review Board (the “Board”), an Ontario tribunal that hears appeals from College complaints, has made numerous comments about problematic penmanship.
In 2019 there have already been several reported decisions by the Board that agreed with the College that physician notes were not legible. In some cases physicians have been warned to make efforts to improve legibility of notes. Multiple physicians have even been ordered to complete a Medical Record-Keeping Course. In addition to these consequences, the physicians will have had to hire legal counsel, incur costs, and spend significant time defending against the complaints. In more serious cases, a medical malpractice lawsuit can be warranted.
So the answer then is yes, physicians really can get in trouble for messy handwriting.
Photo by Samantha Hurley
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