Illegible handwriting in medical records
Open Access
- 1 November 2002
- journal article
- Published by SAGE Publications in Journal of the Royal Society of Medicine
- Vol. 95 (11) , 545-546
- https://doi.org/10.1258/jrsm.95.11.545
Abstract
In clinical records many items are handwritten and difficult to read. We examined clinical histories in a representative sample of case notes from a Spanish general hospital. Two independent observers assigned legibility scores, and a third adjudicated in case of disagreement. Defects of legibility such that the whole was unclear were present in 18 (15%) of 117 reports, and were particularly frequent in records from surgical departments.Keywords
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