MEDICAL RECORD FOR LEGIBILITY OF ELECTRONIC HEALTH RECORD DOCUMENTATION POLICYSUBJECT: Guidelines for legibility of electronic health record documentation.PURPOSE: To set standards for legibility of medical record, provide procedures for evaluating legibility of the records and design corrective measures for illegible and unclear electronic health record. Medical entries must be legible to another reader, it must not be illegible by poor copy quality or bad handwriting.
STAFF GOVERNED BY THIS POLICY: All staff EFFECTIVE DATE: 10/01/18 DATE REVIEWED OR REVISED: 9/29/18DISTRIBUTION: Clinicians, Medical Records Staff, and all staff.POLICY: • All medical record entries must be legible, clear and accurate.• The medical record must be signed, dated and timed.• Identification number must be included with the physician signatures.• Entries not legible will not be accepted for further processing by other staff. • Medical record considered illegible must be corrected timely and accurately. • Regular monitoring of the record using quality audits.
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• Assessment and evaluation of illegible records to yield corrective actions. DEFINITION OF TERMS:LEGIBLE: Entries that two professionals with relevant credentials agree on the entry’s content and clarity. UNCLEAR: Entries that two professionals with relevant credentials cannot agree on the meaning or intent.PROCEDURE: • It is strongly recommended that Nurses, Pharmacists, and Allied Health Professionals present entries of the medical record in organized, legible, clear and systematic manner. • Medical record that is illegible or unclear will not be executed until clarified in writing or by telephone confirmation. • Legibility and clarity should be verified as below: Accurately completed Pre-printed order forms. Legibly handwritten documentation, symbols, and abbreviations are discouraged.
Abbreviations and symbols must be in line with entity approved abbreviations. • Legibility and Clarity: Medical records should be legible, as a notation that can be clearly or easily read. Average healthcare professional should be able to interpret medical record according to the entity. Text message language is not allowed in the documentation.• Timing and Dating of Entries: All entries must be timed and dated as close to the time of the event.
Entries are not allowed in pencil while paper-based entries must be in black or blue.• Legibility peer review conducted and results will be reported to the Medical Staff for each physician’s Professional Practice Evaluations (PPEs). • An illegible entry that results in an adverse event will be referred to the appropriate Departmental Committee and the Risk Management Committee.
CONSEQUENCES FOR FAILURE TO COMPLYIllegible electronic health record can cause errors in the handling of the patient treatment, which could put the patient at risk. At times reading an A as B can cause patients harm, leading to misreading because of illegibility can result in fine, jail, loss of job or revocation or suspension of the erring party license.