Poor handwriting remains a significant problem in medicine

In centuries past, doctors scribbled notes to keep a personal record of the patient's medical history. The notes were generally seen only by the doctor. Today, doctors are no longer one-man bands. With dozens of other professionals, doctors are but one element of a large, multidisciplinary health care team. A consequence of this expansion is that illegible scrawls, hurriedly composed by rushed doctors, are now presented to colleagues with no qualifications in cryptology.

In a BMJ editorial in March 2000, Leape and Berwick called handwritten medical notes a ‘dinosaur long overdue for extinction.’¹ Six and a half years on, the dinosaur is alive and well. In 2002, a report in this Journal revealed that 15% of case histories were illegible.² In 2005, three surgeons audited the legibility of 40 randomly selected operative notes from an orthopaedic ward in a large British hospital.³ Two nurses, two physiotherapists and two medical house officers were asked to rate the legibility of the notes as ‘excellent’, ‘good’, ‘fair’, or ‘poor’. Only 24% were rated ‘excellent’ or ‘good’, and 37% were deemed ‘poor’.

For members of the health care team, deciphering the notes can be a nuisance, sometimes requiring the assistance of colleagues and, if a signature is present and legible, a direct call to the author. Often, no name is left on the form.⁴ The considerable time and frustration associated with this detective work far outweighs the extra effort needed to dot an ‘i’ or cross a ‘t’. Trying to save time by writing quickly is thus a false economy.

From the patient's perspective, illegible handwriting can delay treatment and lead to unnecessary tests and inappropriate doses which, in turn, can result in discomfort and death. In 1999, an American cardiologist caused the death of a 42-year-old patient when his prescription of 20 mg Isordil, an antianginal drug, was misread by the pharmacist as 20 mg Plendil, an antihypertensive drug.⁵ Poor handwriting undoubtedly contributes to another inconvenient truth: the high incidence of medical errors in Britain, which is estimated to cause the deaths of up to 30 000 people each year.⁶

Illegible handwriting in medical records can have adverse medico-legal implications. Stephens notes that ‘few admissions look more damaging in testimony than physicians admitting they cannot read their own handwriting. Sloppy handwriting can be interpreted by the jury as sloppy care’.⁷ In the Medical Defence Union's Ten Commandments of record keeping, ‘Thou shalt write legibly’ comes top of the list.⁸ So, how best to fix this problem? A sophisticated IT system to computerize patient notes? Handwriting tests as part of hospital appointments? Penmanship classes for medical staff, like those conducted in some North American hospitals?⁹ After careful reflection, we propose a less daunting and more economical solution for the graphologically challenged: a New Year's resolution to write more legibly. This commitment must be made, of course, in writing.