Illegible Handwriting

  1. Okay, so I realize that illegible handwriting by doctors is not a new problem, but honestly.....is it really too much to ask that something so important as medication orders and patient treatment be more than just chicken scratch? I'm horrified at the prospect of being the one responsible for deciphering the crappy handwriting I've seen in patient files. I'm only a first year student and I know I have a lot to learn, but this is frustrating because one would think that this problem would have resolved itself long ago due to SAFETY reasons!!! I had a patient record this week where I literally could only figure out the first and last letter of a med!!?? HUHH? That's so wrong. How do you (experienced) nurses figure out bad handwriting? Do you call all the time to confirm orders? Just curious because it seems so unsafe. Thanks for any input.
    •  
  2. 13 Comments

  3. by   hikernurse
    I agree! And it seems the doctors with the worst writing are the ones who most don't like being called to clarify the info (although you'd think they'd eventually see the connection between bad writing and clarification calls...).

    A couple of groups in my hospital have started using computer written orders and it's wonderful! Now if we could get the rest of them to do it...
  4. by   jo272wv
    I agree with you. Nurses are always under the gun to eliminate medication errors even to the point of losing their liecences but doctors are not held accountable for their horific handwriting. If I can not read an order and believe me there are many, I simply call the writing doctor to clarify. If they get angry then I simply tell them If I can not read it I will continue to call and I do. Most of the regular doctors will write more legible when they know I am doing charge so I guess it helps.

    My hospital is going computor (finally), but not until next summer. Phase one will be nursing documentation, Phase two will be physician orders and documentation. This should help a lot, physicians will have hand held computers that will be conected to the system and can write orders from any location. I encourage any nurses in hospital settings to request this be instituted if not already in effect. Medication errors are everyones problem not just the nurses.
  5. by   mandykal
    Frustrating!!!

    Friday, a family member wanted to know EXACTLY how her mother slept if she slept at all the night before. While browsing through nurse's note I could barely read this damn note and that's horrible while the DTR is standing right in front of you....

    As for MD orders or notes, if I can't read it I clarify it with another nurse and if we both can't understand it, then we call the MD for clarification...
    Sometimes lots of nurses work with the same MD's and most of the time they can understand it because of the MD's uniqueness. As always, it's frustrating!
  6. by   meownsmile
    We have always in the past gotten our decipherin crew, ie fellow staff to help however, new rules are we call for any order that isnt clear or is illedgable. I guess they figure if the docs get called on it enough theyll pay more attention. We have faxed written orders back to doctors offices for them to rewrite and/or clearify and requested they fax them back.
    We also have a few staff whose handwritting is rediculously horrid. We fortunately have gone to computer charting and frankly cant wait until they make the doctors go through the computer to write orders. No more guessing and responsibility is right where it should be if he writes the wrong med or misspells something.
  7. by   Medic/Nurse
    I just NEVER guess.

    Call 'em to clarify and then follow the policy on verbal orders that will need the MD review on their arrival to the facility. Enough times HAVING to do that may, at some point, alter their behavior...and HANDWRITING.

    These are $250,000.00+ decisions and I don't make THAT - I'm responsible for ENOUGH for what I make.

    Practice SAFE!
  8. by   S.T.A.C.E.Y
    I think hospitals should have some type of disciplinary action for when Docs write orders that are illegible. Calling the doc to clarify these orders is the right thing to do, but you shouldn't have to do it. Nurses have so many other things to do. I think some type of financial penalty against the docs for each illegible order a nurse had to call for would be a good idea. Maybe orders would start to become readable!
  9. by   climberrn
    Last night a neurosurgeon wrote an order on our patient and when our intensivist (who has marginal handwriting...not horrible but definitely not great) couldn't even read it we all shot him a look like, "Um Pot? Kettle? What? " He actually thought it was pretty funny!
  10. by   Ruby Vee
    [font="comic sans ms"]what is really funny is watching some doctors trying to go back and read their own handwriting! but then again, there are some nurses i've worked with who can't read their own, either!
  11. by   PurrRN
    I want to thank everyone for their insight. It's just 1 of a million things that have been a concern of mine. I realize of course that the right thing to do is to clarify with the doc, I guess I just wondered if a person might not get labeled as incompetent if they were constantly calling the doc back up for clarification. Of course one would hope that the doctors could make that not so difficult connection....but I guess not! Thanks for the input......guess I just now know that I'll be making alot of phone calls in the future if my place of employment isn't computerized.
  12. by   BSNtobe2009
    The last couple of prescriptions that I have taken to get filled, pharmacies are no longer playing the guessing game with handwriting because too many mistakes are getting made. If they can't read it, they don't fill it, and they call the doctor to explain the problem and you have to wait until the doctor calls back.

    Frustrating? Yes. Necessary? Absolutely.

    It's all about what hospitals let doctors get away with.
  13. by   BJLynn
    I will call the doctor's office and speak with his nurse. I've had to have many an order clarified. Ticks me off. I get chewed out if my handwriting gets the least bit sloppy, and these guys (and ladies) get away with scribbles and whatnot.

    But, having said that. I would MUCH rather take the time to get something clarified than to possibly hurt a patient.
  14. by   lovingtheunloved
    I'm a first semester student, and the hospital I do clinicals at does handwritten nurses' notes, and God help me if I can ever read those. Computers, people!

close