Anyone have any tips on how a unit secretary can decipher a doctor's handwriting?

sparky99 · Feb 19, 2009

{{{{Sympathy}}}}}

This is one of the biggest things I worry about regarding nursing! Schools should teach a course in deciphering doctor's handwriting!!!!

I spent some time working in a nursing home and was told that the RN's develop sort of an instinct for handwriting. They could look at handwritten orders that were gibberish to me and make sense out of them. They were amazing! I guess that's what comes of experience. Hang in there!

One more thing - my wonderful gyno now gives a hardcopy of prescriptions typed on computer. May his numbers increase!

liteskin_qtee · Feb 19, 2009

U learn though trial and error. Also, dont be afraid to ask the nurse what it may say. Most of the time she/he knows what order the dr was writing. But its not easy and doctors can be really cranky and intimidating but dont be afraid to ask the dr or ask the nurse to call for clarification.

Just wanted to clarify..when I said trial and error I didn't want u think that its ok if u put a wrong med on the MAR or order the wrong test..I meant just keep practicing and asking for clarification. U will find that eventually u will be able to decipher the chicken scratch...

asunnys · Apr 12, 2009

One of the things that we do to help decipher which doctor wrote the order is keep a list of doctors signatures with their names in print. We just run off a copy of an order and attach it to the list we already have. About once a year we re-copy and arrange all the signatues alphabetically again. (helps when adding in new doctors, especially the hospitalists!)

I wish i could take credit for the idea, but it's still wonderful and helps out a lot. As far as reading the orders themselves, practice is the only thing that has helped me. I've been a unit coordinator for about a year now, and I can deciper about 95% of the handwriting (compared to maybe 20% when I was first hired). Just never be afraid to ask the doctor or a nurse to help figure it out. It's not such a big deal if you read something wrong, but it's huge if you enter in the wrong order.

LovingNurse, BSN, RN · Apr 12, 2009

I was a unit secretary for several years and let me assure you, this experience will serve you very well in your career! It may be weird, but I really love deciphering orders. (Like a puzzle/game one is good at.) Anyway.... you haven't been at it long. It will come. You will learn the common meds, and common orders and it will not always be like this. I'm old enough that I didn't have a computer to look things up.... you have the advantage of the internet and various Rx programs to check medication spelling/doses etc. - but as the other poster mentioned, the nurse (and the person training you) will help you a lot and your skills should steadily increase.

Once you start recognizing the names of some of the meds, take it a step further if you can and try to learn what they are for. Knowing what the meds are for - whether they fit into the puzzle or not is a big part of knowing you are on the right track. We have one sec'y who just writes meds on the MAR as to what she thinks the word looks like. Sometimes she's nowhere even sorta close. I would much rather I be asked than have something being transcribed that she is totally unsure of. The nurse has to sign off the orders anyway, so asking him/her is no big deal and a big resource toward your learning.

If you haven't already... you might consider taking a medical terminology class. You won't regret it. You will learn a ton. Signatures are never easy. We have the copy of signatures on file too, but what works best for me is knowing the doctors and paying attention to who just saw the patient & put down the chart.

I remember one time when none of us on the floor could make out the last order on the page. We had everyone and their brother look at it and try to figure it out. I finally had to call the doctor and ask him what it said. Turns out it said "Thank you" ha-ha! Almost never see that --- no wonder we couldn't figure it out!

Good luck & hang in there!:redbeathe