It’s not only in the clinical arena that people have issues with hand written information and the need to decipher it to get to the part they need. Most of us have come across hand written information that is described at best as scrawl or ‘spider writing’ which cannot be understood by the brightest of minds. When we then take this scenario and put it into the clinical context we have a situation where most of us are pulling our hair out or jumping up and down on the spot as we need to act and we need to act now!
There are many scenarios that I have witnessed in recent weeks where I have had to pull up doctors and nursing staff for writing illegible information trying to explain that it is impossible to deliver care/treatment to a patient(s) if the information recorded cannot be read. But in most cases the author of the notes cannot be read and the contact details are not even available as should be the case for all written clinical entries. Quickly written information is a false economy as the required text is illegible and it takes more time to find out what is actual written and required than reading the information in the first place.
How many medical errors have been contributed to by the fact that notes cannot be understood by colleagues or even the person that wrote them in the first place. There have been cases brought before the courts whereby physicians have admitted they could not read their own writing!
So what is the solution to this problem? A healthcare IT system that makes note taking a lot easier, but what percentage of clinicians have decent keyboard skills, classes in writing skills or testing clinicians on appointment making sure they at least write slower paying as much detail to this as they do to their patients. There isn’t a straight answer, but there are many ways in which we can improve that are not expensive in their approach and could improve quality of care at the point of care saving valuable hours in our working week.