Anonymized dysgraphia

Dr Rodríguez-Vera and colleagues (November 2002, JRSM¹) found that a substantial proportion of clinical records were unclear because of poor handwriting. In the UK, the General Medical Council says that doctors must keep clear, accurate, legible and contemporaneous patient records which report the decisions made and keep colleagues well informed when sharing the care of patients². Good communication between colleagues requires sufficient note-taking as well as legible handwriting. We conducted a survey of the post-take ward round entries in the case notes of 100 patients at Derriford Hospital, Plymouth. We studied the communication in the notes between the admitting team and the doctors who ultimately look after the patients. In 42% of cases the presumed diagnosis (following a consultant's review) was not recorded. Despite a management plan being recorded in 89% of the notes, in 43% there was room for doubt as to whether investigations had been requested or merely proposed. These communication failures were compounded by the fact that in 53% of the records the doctor's name was either illegible or not documented, so that the doctor could not be contacted to clarify the management plan.

It is the responsibility of the doctor to write clear and accurate patient records, something that will not be solved by electronic patient records alone.