How to Read Doctors Handwriting in Medical Records

To read doctors handwriting in a medical record, work from the typed pages toward the handwritten ones. Fix the date, author and kind of note first, collect samples of that writer's letters, look up abbreviations in a published list, and ask the provider about any entry that matters. Record whatever stays unreadable as unreadable.

How do you read a doctor's handwriting in a chart?

You read a doctor's handwriting in a chart by narrowing what each word could be before you look at its strokes. The kind of note tells you its sections, the typed records tell you the drugs and diagnoses in play, and the same writer's clearer words show you how that person forms each letter.

The method is a sequence of passes over the same page. Each pass uses a different source of help, and none of them involves guessing.

Why typed neighbors come first

A handwritten word that might be one of several drug names stops being a puzzle when the pharmacy printout for the same admission lists one of them. Use that as a lead, and then confirm the strokes fit. The typed page tells you what the writer may have meant. Only the handwritten page tells you what the writer put down, and the two can differ.

Where recognition software fits

Converting the whole record set gives you searchable text for the typed pages, which is what makes pass 2 quick. For the handwritten pages, the Schema Law site says recognition is strongest on clean print and weaker on handwriting, and that nothing marks a passage as uncertain. Treat any converted text of a handwritten note as a rough lead to check against the image, never as a reading. The guide to OCR for medical records for attorneys covers converting and organizing the set as a whole.

Handwritten progress notes, orders and prescriptions in older records

In a records set, handwriting turns up on pages a clinician filled in by pen: progress notes, order sheets, prescriptions, operative sketches, and anything that predates the provider's electronic system. Find and tag those pages first, because they need a person's time and the typed pages do not.

Go through the set once and log each handwritten page by type. The type matters because each has its own layout, and layout is half of reading.

Progress notes

A progress note is a dated entry about one visit or one day of a hospital stay. Look for a date and time at the left or top, a block of narrative, and a signature or initials closing the entry. Several writers may share one page, each entry in a different hand, so build a separate alphabet for each. Check whether the note is divided by margin letters or headings, and record what they are before you read the content under them.

Order sheets

An order sheet is a list. Each line is an instruction, such as a medication with a dose and schedule, a test, a diet or an activity level, with a date, a time and a signature. Lines are short, numbers carry the meaning, and there is no sentence to help you. Read each order against the typed medication administration record or pharmacy record for the same day, if the set has one.

Prescriptions

A handwritten prescription packs a drug, a strength, a quantity, directions and a signature onto a small form. The pharmacy's printed label or dispensing record, where you have it, is the typed neighbor. Record both, and say which one your chronology entry rests on.

Forms with handwritten entries

Intake sheets, consent forms and clinic templates mix print and pen. The printed questions convert and the handwritten answers may not. The post on OCR for handwritten forms deals with forms filled in by hand.

A page log that saves rereading

The "Typed neighbor" column tells the next reader where your reading drew its support. An empty cell there is a warning that the reading rests on the handwriting alone.

Medical abbreviations and symbols that look like scribble

A mark that looks like scribble in a chart may be shorthand: two or three capital letters, a symbol, or a dosing instruction. Do not decode it from memory. Look each abbreviation up in a published list, write down which list you used, and check that the meaning makes sense for this patient on this date.

The National Library of Medicine's MedlinePlus site publishes a list of some common medical abbreviations. A few of its entries show what a line of an order sheet or prescription may be made of:

That list is short and written for patients. It will not hold every abbreviation in a specialist's notes, and you should expect to need a second source.

Verify the patient's name, the date, and the signature on a progress note. Verify the drug, the amount, and the date on a prescription. In a medical malpractice chronology, those handwritten lines are the ones you quote when standard of care is under discussion. Health information privacy keeps the chart with the matter team. On a consent form, read the name and the signature next to any informed consent wording.

The same letters can mean different things

The Joint Commission, which accredits hospitals, says in its standards FAQ on terminology, abbreviations, acronyms, symbols and dose designations that standardization adds clarity "when dealing with symbols and abbreviations that may have different meanings, depending on the context of use." Take that as a working rule. MedlinePlus, for example, gives PT as "Prothrombin time", a blood test. If the letters PT appear in a chart beside a referral and no lab value, test that meaning against the page before you adopt it.

Ask for the facility's own list

The same FAQ says accredited organizations "are expected to use standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations", and gives as one acceptable approach "Standardized abbreviations developed by the individual organization." It also says organizations are not required to keep a list of approved abbreviations. So ask. If the hospital or clinic that produced the chart has its own abbreviation list, that list is the best key to its own notes, and a records request can name it.

Symbols and marks

Arrows, circles, plus and minus signs, a letter with a line over it, a triangle: charts use marks that no keyboard carries. For each mark that affects an entry you rely on:

1. Copy it into your notes as a description, such as "upward arrow before BP", not as a meaning.
2. Look for the same mark elsewhere in the same writer's notes, next to typed information that explains it.
3. If you find no explanation in the set, put it on the list of questions for the provider.

Keep a matter glossary

Start a two-column sheet for the matter: the abbreviation or mark as it appears, and the meaning with its source. "BID: twice a day (MedlinePlus)". "Circled R: right, per Dr. Kessler's office, call of 12 June". Anyone who picks up the file later can then see which meanings were looked up and which were confirmed by the writer.

Which abbreviations do hospitals themselves ban as unsafe?

Hospitals accredited by the Joint Commission must follow a list of prohibited abbreviations. The Joint Commission's published minimum covers U and u, IU, the Q.D. and Q.O.D. family, a trailing zero after a decimal point, a missing zero before one, and MS, MSO4 and MgSO4.

The list sits in the Joint Commission's standards FAQ on abbreviations, acronyms, symbols and dose designations. Under the heading "Prohibited Abbreviations" it says organizations "are required to follow a list of prohibited abbreviations, acronyms, symbols, and dose designations, which, at a minimum, includes the following":

• U, u
• IU
• Q.D., QD, q.d., qd
• Q.O.D., QOD, q.o.d, qod
• Trailing zero (X.0 mg)
• Lack of leading zero (.X mg)
• MS
• MSO4
• MgSO4

The FAQ adds that the list "applies to all orders, preprinted forms, and medication-related documentation", and that such documentation "can be either handwritten or electronic."

Where the list came from

The Joint Commission's page on the "Do Not Use" list of prohibited abbreviations gives the history. It issued a Sentinel Event Alert on medical abbreviations in 2001, its board approved a National Patient Safety Goal the following year requiring accredited organizations to develop a list of abbreviations not to use, and "In 2004, Joint Commission created its “Do Not Use” list to meet that goal." The page says the list is now part of the Information Management chapter under Standard IM.02.02.01.

What the list means for someone reading a chart

The list is a warning about exactly the entries a legal reader cares about: doses. Three practical consequences follow.

• Dates matter. An order written before the list existed, or at a facility the Joint Commission does not accredit, may use these forms freely. Do not treat their presence as an error by itself. Note the date and the facility.
• Slow down at these entries. If you meet one of the listed forms in handwriting, read the surrounding characters one at a time, and compare the dose with the typed pharmacy or administration record.
• Watch the decimal point. The two zero entries on the list are about numbers such as "X.0 mg" and ".X mg". When a handwritten dose has a decimal point, or might have one, record the figure exactly as written and flag it for whoever will give an opinion on the dose.

The FAQ makes one exception worth knowing when you read lab pages: a trailing zero "may be used only when required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes."

The Joint Commission's page also notes that the Institute for Safe Medication Practices publishes additional error-prone abbreviations. Whether any entry in your chart reflects a departure from a standard is a question for a qualified expert. Your task with the document is narrower: transcribe the entry as written and make sure the expert sees the image.

Asking the provider for a typed transcription or a dictated copy

Ask the provider when an unreadable entry matters to the case. The writer, or the writer's office, knows the hand and the shorthand, and a reading from the source is something you can attribute. Make the request specific: page, date, and the lines in question.

Start by checking whether a typed version already exists. A handwritten clinic note may have a dictated counterpart, and a hospital stay that produced handwritten daily notes may also have produced a typed discharge summary. Ask the records department whether the set you received is the complete record for the dates, and whether dictated or transcribed notes exist for the handwritten ones.

What the federal access rule says about form

For a patient's own request, the HIPAA Privacy Rule addresses the form of the copy. 45 CFR 164.524(c)(2)(i) says the covered entity must provide access "in the form and format requested by the individual, if it is readily producible in such form and format; or, if not, in a readable hard copy form or such other form and format as agreed to by the covered entity and the individual."

Paragraph (c)(2)(iii) of the same section says the covered entity "may provide an explanation of the protected health information to which access has been provided" if the individual agrees in advance to the explanation and to any fees imposed for it.

Read those provisions for what they are. They describe an individual's right of access and a provider's option, they carry exceptions set out elsewhere in the section, and state law and the discovery rules in your case may add their own routes. How they apply to a request made through counsel is for the lawyer to decide. For document handling, the point is narrower: the rule speaks of the form of the copy and lets a provider give an explanation by agreement, so asking for one is a reasonable request. Nothing in those paragraphs promises a typed version of a handwritten note.

A request that gets answered

1. Identify the patient, the date of service and the provider who signed the note.
2. Attach a copy of the page with the unreadable lines boxed and numbered.
3. Ask one question per box: "Please type the words written in box 2."
4. Ask who is giving the reading: the author, or a staff member reading the author's hand.
5. Ask for the answer in writing, dated and signed.

Keep the response with the page it explains. In your chronology, a reading from the provider is recorded as the provider's reading, with the date you received it. The handwritten page stays in the set unchanged, because the reading is evidence about the note and the note is still the record.

If the author has retired, moved or died, ask whether a colleague or long-serving nurse knows the hand. Record that person's name and role beside the reading.

Marking an unreadable chart entry in a medical chronology

An unreadable chart entry still gets a row in the chronology. Record its date, provider, kind of note and page, say that the content could not be read and how much of it, and note what you did to resolve it. A missing row tells the reader nothing happened that day.

The row should let a reader weigh the gap without opening the record. A fictional example from a file for a client named Marisol Venn:

The marks in the content column follow the conventions in the guide on how a transcript should mark words nobody can read. Use the same marks in the chronology that you use in any transcript in the matter.

Five things the row must not do

• Paraphrase past the gap. "Exam unremarkable" is a finding. If the exam lines are unread, the chronology cannot say what they found.
• Borrow from the typed neighbor silently. If the drug name comes from the pharmacy record, cite the pharmacy record's page for it, and leave the prescription's own entry bracketed.
• Hide the size of the gap. One word and half a page are different problems. Give an estimate.
• Drop the abbreviation. Quote "PT 2x/wk" as written. An expansion belongs in the glossary with its source.
• Lose the follow-up. The status column is a task list. When the provider answers, update the row and keep the earlier status in a note.

Count the gaps before the chronology goes out

Before a chronology goes to an expert, an adjuster or opposing counsel, filter the status column and count the open entries. Put the count in the covering note: "Fourteen handwritten pages in the set. Eleven read in full. Three contain unread passages, listed by page." A reader who knows where the gaps are can ask for the images. A reader who finds one unannounced starts doubting every other row.

Chart pages are sensitive papers. If you use an online converter for the typed portion of the set, read what the service says it does with uploads first. Schema Law's commitments are listed under security on the homepage.