Legibility and Communication - Tips to Help Ensure Patient Safety

Physicians have a responsibility to communicate clearly to both patients and to other members of the health care team. Physicians are often rushed, meaning that handwriting suffers. This makes patient information difficult for others to read and medical orders harder to safely implement. Poor legibility is responsible for a large percentage of medical errors and increases your liability if a treatment or medication error results in injury or death.

Tips for improving handwriting legibility and communication:

• Support Computerized Physician Order Entry (CPOE)
• Use preprinted forms when available
• Use a ball-point pen; never use felt-tip markers
• Slow down and print if necessary
• Ask patients if handwritten instructions are clear to read and understandable
• At the hospital, ask the nurse or unit secretary if your orders are clear before leaving the unit
• Print your name and contact number below your signature
• Become a peer leader and champion improved legibility as a goal in hospitals
• Take a penmanship class if offered at an area hospital or elsewhere
• Use a transcriptionist or electronic medical record
• Many drug names are similar; be sure to spell them clearly