While going over a patient's chart, you notice that there are several comments and markings that are illegible.
What should you do in this situation? Explain.
In what ways do you think poor legibility impacts different users of medical records?
What are some of the legal ramifications of illegible entries?
Other than writing more clearly, what are ways that you can suggest to help improve legibility?
The best procedure to follow when you find illegible notes on a medical record is to go to the source- ask the doctor that wrote them. Doctors should be asked to re-write a note for clarity or dictate the note. You should never "guess" what it is written. Illegible handwritten notes can affect all levels of patient care. For example, pharmacists have to read the physician`s prescription to dispense and nurses need to understand it to administer the correct medication to patients (Institute of Medicine, 2000). Patients also need to understand the instructions to follow treatment. The Centers for Medicare and ...
Solution Summary
The solution discusses the options available when illegible notes or comments are found on a patient's chart. It includes how these illegibles notes or comments can impact diferent users of the medical records, legal ramifications and solutions to prevent illegible notes on chart.
... paper records are often unavailable, missing important information, or illegible. ... with paper records and documentation, especially the medical records staff. ...
... EFFECTIVE COMMUNICATION ENCORAGED BY ELECTRONIC MEDICAL RECORDS. ... Errors caused by illegible handwriting can be eliminated and communication between other ...
... Having an electronic medical record reduces the chance of making an error by ... the pharmacist to call the physician's office to verify an illegible prescription. ...
... is human error whether it's insufficient information, illegible entries or ... According to the Medical Records Institute (MRI), an organization committed to ...
... Poor reading comprehension Poor spelling Illegible handwriting ... of each year of medical school and ... Clerkship directors must keep records of all requests ...
... Parts -. The diabetic clinic uses electronic medical records for each patient. ...illegible writing. Implementation of the Pyxis system in the Pharmacy provides: ...
... not matching the code biller, inability to find hospital record and illegible handwriting ... Part A Hospital, Part B Medical and Prescription Drug coverage and ...
