Illegible handwriting in medical records

Rodríguez-Vera, F.J.; Marín, Y; Sánchez, Ángel; Borrachero, C; Pujol, Emilio

doi:10.1258/jrsm.95.11.545

Cited by 62 publications

(24 citation statements)

References 7 publications

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“…The Four Point Scale is an ordinal scale of handwriting legibility that has been researched and modified for use with adults (Au et al, 2012). The Four Point Scale was designed to rate the global legibility of health professionals who write in medical records (Berwick & Winickoff, 1996;Rodriguez-Vera, Marin, Sanchez, Borrachero, & Pujol, 2002). The original version of the Four Point Scale scored legibility as 'poor', 'fair', 'good' or 'excellent' (Berwick & Winickoff, 1996).…”

Section: Assessmentmentioning

confidence: 99%

Feasibility of a home-based program to improve handwriting after stroke: a pilot study

Simpson

McCluskey

Lannin

et al. 2015

Disability and Rehabilitation

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facilities, health-related websites and in a seniors' newspaper. Eligibility criteria included having sustained a stroke at least three months previously, having self-reported difficulties with, and goals related to, handwriting, being able to hold a pen, and having sufficient cognitive and communication skills to complete a daily home program.A four-week, home-based handwriting training program was delivered by an occupational therapist. The intervention applied principles of task-specific motor training, involving intensive practice of meaningful handwriting tasks related to participant goals. Whole handwriting tasks were practised, as well as problematic handwriting task components. An occupational therapist provided supervised practice and coaching, giving feedback on task performance and using shaping to achieve the right level of challenge. Two 1-hour therapy sessions were provided per week. Another three hours per week of independent, unsupervised practice was prescribed to increase practice intensity. Participants were taught cognitive strategies to analyse their handwriting performance and problem-solve ways to improve specific handwriting features.Handwriting performance was measured at baseline, after the training program (at four weeks) and four weeks later. The primary outcome measure was the modified Evaluation Tool of Children's Handwriting-Words (mETCH-W), a subtest of the Handwriting Assessment Battery (HAB). Secondary outcome measures included other subtests of the HAB, the modified Four Point Scale, and the modified Disability of the Arm, Shoulder and Hand (DASH) Scale. Legibility was scored by a blinded rater.Feasibility of recruitment, intervention and outcome measures was evaluated using descriptive statistics, including means, standard deviations and proportions. Utility of the outcome measures was also evaluated by comparing participant score at baseline, postintervention and follow-up. Mean or median change scores were then calculated between these three time points and reported with a 95% confidence interval or interquartile range.Results: Seven adults with stroke were recruited over 18 months (eligibility fraction 43% of those screened, and enrolment fraction 78% of those eligible). There were no dropouts. Mean time post stroke was 2.6 years (range: 3 months to 7 years). Mean age was 71 years (range: 50 to 87 years). Mean disability measured using the Modified Rankin Scale was 2.3 (range 1 to 4). Although recruitment was slow, the intervention was feasible. Participants completed a mean of 7.9 hours of occupational therapy supervised handwriting practice (range: 7.6 to 8.3 hours) and 10 hours of independent practice (range: 6 to 14 hours). Participants were able to

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Section: Assessmentmentioning

confidence: 99%

Feasibility of a home-based program to improve handwriting after stroke: a pilot study

Simpson

McCluskey

Lannin

et al. 2015

Disability and Rehabilitation

View full text Add to dashboard Cite

show abstract

“…In the study the results were given for each speciality individually. This showed that the worst scores belonged to the surgery department 10 . Another study, carried out in a university hospital in Switzerland, evaluated the legibility of medical prescriptions.…”

Section: Historymentioning

confidence: 94%

“…A doctor should have perfectly legible (if not nice) handwriting always. It is not acceptable that, out of 117 reports written by doctors 18 (15%) can simply not be read 10 , and even worse, if that were possible, that 4% of the prescription evaluated as illegible and 52% as difficult to read, as seen in the study by Hartel et al 11 . We have already seen the consequences which inappropriate writing may have.…”

Section: Historymentioning

confidence: 99%

La letra de médico

Bordón

Castellano

Rodríguez

et al. 2014

Rev Osteoporos Metab Miner

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“…[6] In Australia, records showed a severe deficiency of items and were illegible, incomplete and un-integrated. [7] Rodriguez-Vera et al [8] also found 15% of records to be illegible in Spanish records audited. In previous South African studies, at least a third of records were illegible.…”

Section: Audit Of Medical Records: Use Of a Structured Form In Emergementioning

confidence: 99%