Deciphering a Doctor’s Handwriting

DERP

Today, I came across some handwritten reports from a gynaecologist that I had to file for our clinic. The medical clinic assistants here fear these reports because most are hard to read. There is this one doctor known to all of us working here whose handwriting we just cannot decipher! I am sure that I am not the only one who has always wondered why most (not all) doctors’ handwriting are sometimes difficult to read. It is still a mystery to me and I am too scared to ask my doctor :P

Keep reading if you want to know

  1. How dangerous sloppy handwriting can be
  2. How I go about deciphering a doctor’s handwriting

 “Cause of Death: Sloppy Handwriting” (Time, 2007)

What surprises me is how Pharmacists were able to read drug prescriptions written by these doctors before technology advanced. According to Time (2007), doctors’ sloppy handwriting kills more than 7000 people annually in the United States. Currently, doctors are transitioning into printing prescriptions electronically. This way, the type of drug, dosage amount, abbreviations are all clearly legible. “We have the technology today to prevent these errors, so why aren’t we doing it?”

Speaking of abbreviations, some abbreviations should not be used because it can have multiple meanings or can be easily mistaken for something else if handwriting is sloppy. There are some health care providers who believe that given the context and sufficient medical training, these abbreviations should not be a problem and are common sense. Personally, as a health care worker, we should know better than to assume others understand what we mean. Different people interpret the same thing differently. It is better to assume that the other person has very basic medical knowledge and go from there. Therefore, it would still be in the best interest of both the person who is reading it and the patient if the full word is written out whenever possible. Don’t be lazy, write clearly!

Why the Sloppy Handwriting, Doc?

  • “I have been writing like this all my life! I was born to be a doctor!”
  • “I am a busy doctor! Who has time to write neatly?”
  • “It is legible to me, it should be legible to you”

How I Decipher Doctor’s Handwriting

gyno note

This doctor’s writing is pretty neat :) Good for practice here!

 

1. Content

Where did this report come from? What is the doctor who wrote this report specialized in? Once you know what general area the report is talking about, try reading the report. It is okay if you cannot read some of the words, skip those for now. You want to get the gist of the report.

The above report is written by a gynaecologist. Automatically, female and all lady parts should come to mind. Distinguishable words that are important are “PAP”, “IUD”, and “Ultrasound”. At first glance, the first line looks like “Menu: new light” to me. After understanding that it is from a gynaecologist, I figured it should be read “Menses: very light”.

2. Abbreviations

Identify and define any abbreviations. See my list of common medical abbreviations that I have compiled according to what I come across repeatedly.

    • P = Plan
    • O/E = On Examination
    • IUD = Intrauterine Device
    • RTC = Return to Clinic
    • U/S = Ultrasound
    • D&C = Dilation and Curettage

3. Ask Google or a Friend

If there is anything you cannot read or do not know, guess the word and search it on Google. I do this by searching “__(word/abbreviation I guessed)__ medical abbreviation”.

Asking a friend also helps because different people see things differently. On the third line, one of the words look like “glim” to me but my friend said it looks like “slim”. Her interpretation would make more sense in this context.

Accept that sometimes you just do not know. I do not know what +/- means :S

4. Wrap it Up

  • Menses: Very light
  • No meds, last PAP ~ 1 year ago
  • On Examination: Slim, nothing abnormal detected
  • Per vagina: No intrauterine device string seen, IUD hook used, no IUD
  • Plan: Ultrasound to check position of IUD
  • Return to Clinic after ultrasound +/- Dilation & Curettage for removal

Try it Yourself! 

doc2

Comment below what you think this reads! This is a report from a gynaecologist.

I personally think it is fun trying to decipher a doctor’s handwriting. It is a challenge that can (sometimes) be conquered with the steps outlined above. It feels awesome when you can read a Doctor’s writing!

*Note: If you are a Health Care Provider, please do your best to write legibly in the best interest of your patient and the next person who has to read it!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s