An illegible medical record is doubly damaging to a physician: it obscures necessary information, and it makes the physician who wrote the entry look less than professional. A favorite strategy of plaintiffs’ attorneys is to make enlargements of illegible medical records and use them to belittle the defendant physician in front of the jury. Despite the jokes about physicians’ handwriting, juries are not tolerant of illegible records.
The best way to ensure that records are legible is to dictate them. This may be done on a pocket tape recorder while the physician is still with the patient or immediately after. In all cases, the dictation should be done before the physician sees another patient. If recordkeeping is delayed, it is inevitable that entries will be lost or distorted. The tape should be transcribed daily and the transcription entered into the chart. This entry may be made by affixing the actual typescript to the medical record. If a computer or memory typewriter is used for the transcription, then the entry, after proofing, may be printed on the chart page itself.
Handwritten notes should always be made in the chart in case the transcription is delayed or lost. The transcribed notes should not be pasted over the handwritten notes; both sets of notes are part of the legal record and must be preserved. If the chart entries are not dictated, all entries should be made in black ink—never in pencil. It is best if they are printed, but legible cursive handwriting is acceptable. The records should be spot-checked for legibility from time to time. Taking the time to write one legible sentence makes for a better record than a hastily scrawled page of illegible notes.