Although the advent of computerised medical records and prescriptions has largely decreased the incidence of medical mismanagement due to illegible doctors’ notes and instructions – the importance of clear, accurate, detailed and contemporaneous record keeping remains as essential as ever.
Many modern practices are essentially paperless, but especially within both public and private hospitals, the clinical records remain largely handwritten. Outside the hospital system, handwritten communication is decreasing, but still remains a trap for the ill-equipped, careless or unwary.
In a 1997 research study conducted at a US hospital, 20% of the medication orders and 78% of doctors’ signatures were illegible or legible with effort.[1] These results indicate there is a significant problem with the system, highlighting the risk for medication errors and patient harm. Several research studies have also noted the correlation of illegibility with poor patient outcome.[2]
An obligation to keep legible and clear medical records is recognised in the Medical Board of Australia’s Code of Conduct for Doctors in Australia under clause 8.4. This Code emphasises the importance of maintaining clear and legible medical records. Repeated failure to meet the standards of the Code may have consequences relating to medical registration, and a potential finding of professional misconduct or unprofessional conduct.
The risks associated with miscommunication of handwritten instructions both between doctors, and from doctors to pharmacists, allied health and others, are obvious. The doctor may understand his or her own handwritten records or prescriptions. However, the issues arise when other parties become involved. For example, pharmacists and nurses rely on and interpret the doctor’s prescription to dispense and administer the correct medication to patients, and in the event that a prescription is misinterpreted the consequences can be catastrophic.
An example of a potential serious consequence is outlined in the recent NSW court case of Hirst[3]. This case related to the birth of a child who suffered from severe disabilities including cerebral palsy. It was alleged that the child would have been better off had an ultrasound been ordered at 36-37 weeks into her mother’s pregnancy. Proceedings were initiated in relation to the reading of one unclear word in a handwritten consultation note written by the obstetrician. The illegible word disputed was believed to have read either “seen” or “scan”. The obstetrician claimed the word written was “seen”, however, this was not accepted by the Court. The judge settled on a finding that the child would have been 20% better off, had she been treated at the time the scan was initially contemplated by the obstetrician.
In a 1999 US case Vasquez v Albertson,[4] the patient died after a pharmacist misread a hand written prescription for heart pain medication written by the patient’s cardiologist. Not only did the patient receive the wrong drug, but was instructed to take the drug at eight times its recommended maximum daily dosage. As a result of the cardiologist’s negligence in this case, a number of American states have subsequently passed legislation making doctors’ illegible handwriting a fineable offence. Whilst no such explicit penalties exist in Australia, the Victorian Civil and Administrative Tribunal has made compulsory counselling sessions for practitioners to address the legibility and content of medical records.[5]
Medical defence funds continually implore doctors to keep legible, accurate, detailed and contemporaneous medical records. Despite this, it is one of the most common problems faced by defence teams if medical negligence proceedings are instituted. No matter how careful a doctors’ conduct and verbal communication skills, the clarity of his or her notes will always be a key element in proving innocence. Handwritten notes are often produced as evidence in medical malpractice cases and incomplete and illegible notes may be a source of weakness in a doctor’s defence.[6] As highlighted by the decision in the 2011 NSW case, King v Western Sydney Local Health Network,[7]evidentiary weight of detailed, legible, contemporaneous records is almost always favoured over contradicting oral evidence between patient and doctor.
In an audit conducted at an Australian hospital in 2008, 190 operative surgical notes were audited for patient identity details, preoperative diagnoses, operation details, postoperative instructions and the author of the note. Results suggested that only 92 of the initially audited notes were complete and entirely legible.[8] These results provide material evidence that handwritten surgical notes can generate potential errors, and may lead to confusion when notes are to be reviewed for further follow up or produced as evidence in a legal dispute.[9]
Regardless of the emergent use of computerised medical records and prescriptions, the concerns of unclear or illegible notes remain of fundamental importance. Collective efforts and awareness raising are essential to reduce the incidence of disastrous consequences.
[1] Winslow EH, Nestor VA, Davidoff SK, et al, Legibility and completeness of physician’s handwritten medication orders, Heart & Lung, 1997 Mar-Apr;26(2):158-64.
[2] Rodriguez-Vera F Javier, Marin Y, Sanchez A, et al, Illegible handwriting in medical records, JRSM, 2002 Nov;95(11):545-6; Anon, The handwriting’s on the wall, People’s Medical Society Inc, 2000 Aug;338(7693):548.
[3] Hirst v Sydney South West Area Health Service [2011] NSWSC 664.
[4] Vasquez v. Albertson 3, Inc., No. A-103,042 (Tex., Ector County Dist. Ct. Oct. 19, 1999).
[5] Medical Board of Australia v Lai (Occupational and Business Regulation) [2011] VCAT 1754 (14 September 2011).
[6] Lefter LP, Walker SR, Dewhurst F, et al. An audit of operative notes: facts and ways to improve, ANZ J Surg, 2008 Sep;78(9):800-2.
[7] [2011] NSWSC 1025.
[8] Lefter, op. cit., 800-2.
[9] Ibid.
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Michael has also worked for government health advisory and regulatory bodies, equal opportunity and human rights commissions, a government bio technology ethics committee and a government infertility treatment authority/assisted reproductive treatment authority. Outside health, Michael has been active in United Nations, environmental and Indigenous reconciliation causes.
Michael is Member of the Order of Australia and in 2011 and 2012 was recognised by Best Lawyers 2011 and 2012 for expertise in Health and Aged Care law.
