Here's an article I found concerning this:
What can we do about illegible physician handwriting?
Q: As part of our ongoing record review, we are monitoring legibility of handwritten entries in medical records. What would be the appropriate process to follow when addressing legibility of a physician's handwriting? I would like to have some options for corrective action when I approach the medical staff with this issue.
A: Hospitals that allow handwritten notes must develop standards on how to address physician handwriting. Establish a procedure if hospital staff can't read a chart. For example: If legibility problems arise, physicians must be available within a certain time frame to either dictate or re-write a note for clarity.
According to medical documentation guidelines, if a chart note was not documented, the service was not done. That's also true if the chart is illegible and a CMS (Centers for Medicare and Medicaid Services) auditor can't read it. Since a physician's notations in the medical record are an important part of treatment, illegible notes create a serious problem for all health care providers who need the information for follow up care.
Some organizations are switching to electronic medical records (EMR) to avoid these, and other problems, including the legibility issue. EMRs also help to reduce process and patient errors due to illegible or incomplete notes. However, EMRs are expensive and take years to implement.
If workers are repeatedly asking physicians to rewrite notes, hospital administration and/or the applicable medical staff committee should meet with them to review the problem and assess remedies. If, even after education or other corrective action measures, physicians continue to produce illegible medical records, it could be an indication that you have an ineffective compliance program.
Set up a policy so physicians are clear that if they fail to improve their legibility, you could terminate them from the medical staff. This is rare, but you can avoid it through education, collaborative dialogue, and automated resources, like EMR and dictation services.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join