To those unfamiliar with medical records, a review of the documentation can be a real challenge.  Not only are medical records full of abbreviations (many of which are relevant only to a particular facility), terminology composed of Latin and Greek, poor or missing punctuation, and spelling errors, but the often illegible handwriting makes interpretation downright difficult.

Legal nurse consultants play a pivotal role not only in translating medical records but in identifying their significance.  This is a common part of my daily job.

Deciphering handwriting from medical records is a skill that many legal nurse consultants learn through trial and error. Here are some tips to help you decipher your next set of records full of illegible handwriting. .

• Use your judgment to decide how much time to spend deciphering.  If the record does not have any direct bearing on the case (i.e. 8 year old family practice records about a visit with complaints of a nail fungus for a patient who died unexpectedly from a ruptured an aneurysm.) don’t waste hours trying to figure out a particular word or phrase.
• Invest in a good magnifying glass. I particularly like the full page magnifiers.  When working with electronic medical records, use the zoom option on your PDF reader to blow up hard-to-read sections.
• Review and compare typed reports such as consults, discharge documents, and histories and physicals first against that of the handwritten notes.  They often contain the same information. Consults and discharge documents usually give the name and specialty of consulting physicians too.
• If you have trouble reading the physician’s signature, check the nursing notes. Nurses will sometimes chart the names of physicians in their documentation.
• Physicians’ orders may be more legible than their progress notes or progress notes may be more legible than orders. Comparing the orders to the progress notes, especially the plan of care, often can help the legal nurse consultant identify specific words.
• Consider the context of the note.  For example, pulmonologists discuss respiratory issues so look for words and abbreviations used by the particular specialty such as DOE, SOB, dyspnea, ABGs, etc. Flipping to the nursing notes for the same time period may also give you clues to what the physician’s note entails.
• Try to interpret all the bad handwritten notes in one sitting. Sometimes you’ll be able to read words in a later note which will enable you to understand earlier notes.
• Conversely, it may help to let the task of deciphering sit for a day or two. Sometimes words that eluded you earlier will pop out at you after a few days.
• Use the process of “fresh eyes.” If you have access to another legal nurse consultant, ask her or him to view the problematic handwriting and give you suggestions.
• Lastly, consider using a yellow filter.  Sometimes the use of a yellow tinted filter will help you to focus and better identify that squiggle.

Now get to reading those records and remember the difficulty of this task the next time you leave handwritten notes for another!

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