When an attorney takes on a medical-related lawsuit, the attorney is oftentimes confronted with enormous volumes of medical records which are crammed with esoteric terminology, inexplicable shorthand and indecipherable handwriting. Yet his client’s future depends on his/her understanding the records. The attorney must also be able to use the information to effectively support the case. This is why Legal Nurse Consultant services are one of the greatest additions to an attorney’s practice.

A major portion of the legal nurse consultants job is to interpretation medical records.  This can be a real challenge.  Not only are medical records full of shorthand, abbreviations (many of which are relevant only to a particular facility), terminology composed of primarily Latin, poor or missing punctuation, and spelling errors, but the often illegible handwriting makes interpretation downright difficult.

There are numerous jokes about doctor’s handwriting.  I haven’t met a nurse yet who didn’t complain about the awful task of interpreting orders or progress notes.  A Time article indicated that sloppy handwriting by physicians is responsible for killing some 7,000 people per year.  It is no laughing matter.  (A study was actually held in 1998 to prove that doctor’s handwriting was worse than that of the general public, but it failed to pan out.)

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. .

• Never assume Read slowly and practice patience making sure that the words make sense as you go.
• Use your judgment on how much time you should spend trying to figure it out.  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.
• Use 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.
• Piece together what you know Using letters from words in the document that you can read will help you to piece together the letters in words you can’t read.
• If you have trouble reading the signatures within the record, check the signature page often found in the back of the records.  You should also check the nurses notes. Nurses sometimes chart the names of physicians when documenting their calls or rounds on the patient.
• Spelling errors Keep in mind that not everyone can spell.  Some words may even be spelled differently within the same document.
• Compare the doctor’s orders to the progress notes and vice versa.  This can often help you to identify specific words.
• Pay special attention to the letters I and J, L and S, L and T, M and N, T and F, and U and V.  These capitol letters can look very similar.
• 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.
• It may help to let the task sit for a day or two. Sometimes words that eluded you earlier will pop out at you after a few days.
• Use a pair of fresh eyes. If you have access to another nurse, ask him/her to read the problem section and give you suggestions. Don’t tell them what you think it is or that may be all they can read.  It is better to let them consider the information without any input.
• Try reading the section aloud. Sometimes if you read the section a few times, in different ways and aloud, you can suddenly make sense of it.
• 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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