Illegible Handwriting in Medical Records

Methodological issues of the electronic health records' use in the context of epidemiological investigations, in light of missing data: a review of the recent literature

BACKGROUND

Electronic health records (EHRs) are widely accepted to enhance the health care quality, patient monitoring, and early prevention of various diseases, even when there is incomplete or missing information in them.

AIM

The present review sought to investigate the impact of EHR implementation on healthcare quality and medical decision in the context of epidemiological investigations, considering missing or incomplete data.

METHODS

Google scholar, Medline (via PubMed) and Scopus databases were searched for studies investigating the impact of EHR implementation on healthcare quality and medical decision, as well as for studies investigating the way of dealing with missing data, and their impact on medical decision and the development process of prediction models. Electronic searches were carried out up to 2022.

RESULTS

EHRs were shown that they constitute an increasingly important tool for both physicians, decision makers and patients, which can improve national healthcare systems both for the convenience of patients and doctors, while they improve the quality of health care as well as they can also be used in order to save money. As far as the missing data handling techniques is concerned, several investigators have already tried to propose the best possible methodology, yet there is no wide consensus and acceptance in the scientific community, while there are also crucial gaps which should be addressed.

CONCLUSIONS

Through the present thorough investigation, the importance of the EHRs' implementation in clinical practice was established, while at the same time the gap of knowledge regarding the missing data handling techniques was also pointed out.

Recording adverse events following orthopaedic trauma: Financial implications and validation of an adverse event assessment form in an Irish regional trauma unit

BACKGROUND

In Ireland, funding of orthopaedic trauma is based on an activity-based funding (ABF) model. Clinically similar cases are split into diagnostic-related groups (DRG), with base funding per DRG provided. Increased complexity of cases (length of stay; complications incurred; occurrence of adverse events) attracts additional remuneration to the base funding. In our institution these adverse events are recorded via retrospective chart-abstraction methods by administrative staff. Incidences which are not included from this review affect both follow up with family physicians and patient care; as well as skewing budgetary decisions that impact fiscal viability of the service. The aim of this study was to compare a prospectively implemented adverse events form with the current national retrospective chart abstraction method. Our outcomes in terms of pay-by-results financial implications.

METHODS

An adverse events database adapted from a similar validated model was used to prospectively record complications in 216 patients admitted via the orthopaedic trauma service. Data was contemporaneously collected via a GDPR compliant secure medical messaging platform. Results were compared with the same cohort using an existing data abstraction method. Both data sets were coded in accordance with current standards for case funding.

RESULTS

Overall, 49 adverse events were recorded during the study through prospective charting of adverse events, compared with 26 events documented by customary method (p<0.01).Anaemia requiring blood transfusion n = 11 22.4%) was the most common complication, followed by delirium n = 6 (12%), acute kidney injury n = 6 (12%), and pneumonia n = 5 (10.2%). Missed appropriate funding through conventional methods totalled €40,293 .

CONCLUSION

This pilot study demonstrates the ability to improve capture of adverse events through use of a well-designed assessment form. Proper perioperative data handling is a critical aspect of financial subsidies, enabling optimal allocation of funds.

Digital disparities among healthcare workers in typing speed between generations, genders, and medical specialties: cross sectional study

OBJECTIVE

To investigate the typing skills of healthcare professionals.

DESIGN

Cross sectional study.

SETTING

Two large tertiary medical centres in Amsterdam, the Netherlands.

PARTICIPANTS

2690 hospital employees working in patient care, research, or medical education.

MAIN OUTCOME MEASURES

Participants completed a custom built, web based, Santa themed, typing test in 60 seconds and filled out an associated questionnaire. The primary outcome was corrected typing speed, defined as crude typing speed (words per minute) multiplied by accuracy (correct characters as a percentage of total characters in the final transcribed text). Feelings towards administrative tasks scored on the Visual Analogue Scale to Weigh Respondents' Internalised Typing Enjoyment (VAS-WRITE), in which 0 represents the most negative and 100 the most positive feelings towards administration, were also recorded.

RESULTS

Between 18 and 21 May 2021, a representative cohort of 2690 study participants was recruited (1942 (72.2%) were younger than 40 years; 2065 (76.8%) were women). Respondents' mean typing speed was 60.1 corrected words per minute (standard deviation 20.8; range 8.0-136.6) with substantial differences between professions and specialties, in which physicians in internal medicine were the fastest among the medical professionals. Typing speed decreased significantly with every age decade (rho -0.51, P<0.001), and people with a history of completing a typing course were more than 20% faster than those who had not (mean difference 12.1 words (standard error 0.8), (95% confidence interval 10.6 to 13.6), P<0.001). The corrected typing speed did not differ between genders (0.5 (0.9) words, (-1.4 to 2.4), P=0.61). Women were less negative towards administration than were men (mean difference VAS-WRITE score 7.68 (standard error 1.17), (95% confidence interval 5.33 to 10.03), P<0.001). Of all professional groups, medical staff reported the most negative feelings towards administration (mean VAS-WRITE score of 33.5 (standard deviation 22.9)).

CONCLUSIONS

Important differences were reported in typing proficiency between age groups, professions, and medical specialties. Specific groups are at a disadvantage in an increasingly digitalised healthcare system, and these data could inform the implementation of training modules and alternative methods of data entry to level the playing field.

Impact of Illegible Prescriptions on Dispensing Practice: A Pilot Study of South African Pharmacy Personnel

Illegible prescriptions are an illegal, frequent, and longstanding problem for pharmacy personnel engaged in dispensing. These contribute to patient safety issues and negatively impact safe dispensing in pharmaceutical delivery. To date, little is documented on measures taken to assess the negative impact posed by illegible prescriptions on South African pharmacy dispensing personnel. Therefore, this pilot study was performed to evaluate the ability of pharmacy personnel to read and interpret illegible prescriptions correctly; and to report on their perceived challenges, views and concerns when presented with an illegible prescription to dispense. A cross-sectional, three-tiered self-administered survey was conducted among pharmacy personnel. A total of 885 measurements were recorded. The ability to read an illegible prescription is not an indicator of competency, as all (100%) participants (novice and experienced) made errors and experienced difficulty evaluating and deciphering the illegible prescription. The medication names and dosages were correctly identified by only 20% and 18% of all participants. The use of digital prescriptions was indicated by 70% of the participants as a probable solution to the problem. Overall, improving the quality of written prescriptions and instructions can potentially assist dispensing pharmacy personnel in reducing illegible prescription-related patient safety issues and dispensing errors.

Clinical Documentation Practice: A Study of Doctors' Medical Documentary Compliance in Government Hospitals in Gampaha District, Sri Lanka

Doctors play a key role in health information system through clinical documentation. The study aimed to assess doctors' compliance with national medical documentation standards. The study was carried out in government hospitals having in-ward patient care facilities in Gampaha district, Sri Lanka. The doctors' knowledge and practices were assessed using a questionnaire. 500 Bed Head Tickets (BHTs) which are the medical records of inward patients, were audited in selected government hospitals in the same district using a check list to ascertain the doctors' compliance with standards in practice. Only 29.46% doctors were aware of the government circular on standards of medical record. Although 82.84%, 66.37% and 76.3% doctors knew that final diagnosis should be written according to International Classification of Diseases (ICD) 10, in block capitals and without any abbreviations, respectively. Only 7.61% BHTs were found to have fulfilled all standards. There were gaps in the knowledge of doctors regarding standards in clinical documentation practice. The awareness of and reference to published guidelines were not satisfactory. Poor transfer of knowledge into practice was evident by the results of BHT survey. As publishing guidelines or teaching alone may not improve the compliance of doctors with the standards in clinical documentation practice, more innovative strategies should be sought for.

Audit of international intraoperative hemotherapy and blood loss documentation on anesthetic records

BACKGROUND

Anesthetic records facilitate information transmission to the next healthcare professional and should contain all relevant information of perioperative care. While most anesthesia societies provide guidelines for record content, important topics like hemotherapy and hemostatic therapy are not well represented. We considered the quality of anesthetic records with regard to the documentation options for hemotherapy and hemostatic therapy. A secondary objective was to examine guidelines for appropriate recommendations.

METHODS

Anesthetic records of international anesthesiology departments were evaluated for the presence of 20 defined fields associated with hemotherapy, hemostatic and fluid therapy as well as intraoperative diagnostics and monitoring. International guidelines were reviewed for appropriate recommendations.

RESULTS

A total of 98 anesthetic records from eight countries and guidelines of six anesthesia societies were analyzed. Data fields for red blood cell transfusion have been found in 29.3% (95% CI 0.20 to 0.38), ABO-testing in 6.1% (95% CI 0.01 to 0.11) and indication for transfusion in 2.0% (CI 0.00 to 0.05) of records. Most records contain fields for blood loss (94.4%; 95% CI 0.91 to 0.99) and diuresis (87.9%; 95% CI 0.81 to 0.94). International guidelines that were analyzed do not cover the topic of transfusion, but most give recommendations on basic monitoring, blood loss and fluid management documentation.

CONCLUSIONS

Most of the evaluated anesthetic records did not contain fields for relevant aspects of perioperative hemotherapy, hemostatic therapy and diagnostics. Guidelines and protocols for anesthetic documentation should include these topics to ensure information transfer and patient safety.

[Success, satisfaction and improvement of informed consents for computed tomography : A survey among patients and physicians]

Hintergrund

Die Aufklärung eines Patienten vor einer Computertomographie (CT) spielt sowohl für die aufklärenden Ärzte als auch für die Patienten eine entscheidende Rolle. Ein persönliches Aufklärungsgespräch über die Durchführung, Risiken und mögliche Alternativen ist vor einer CT-Untersuchung verpflichtend.

Methode

Durchgeführt wurde eine Befragung zur Patientenzufriedenheit hinsichtlich der Dauer und den Inhalten einer CT-Aufklärung. Befragt wurden hierüber auch aufklärende Ärzte. Ein weiterer Teil der Befragung beschäftigte sich mit der Akzeptanz technischer Hilfsmittel, wie z. B. Informationsvideos oder Tablets/PCs.

Ergebnis

Insgesamt 512 Patienten und 106 Ärzte beteiligten sich an der Befragung. Die Dauer des Aufklärungsgesprächs gaben die Patienten mit durchschnittlich 4,08 min und die Ärzte mit 4,7 min an. Am ausführlichsten klärten die Ärzte über die Nebenwirkungen von Kontrastmitteln auf. Über mögliche Alternativen und die Notwendigkeit der Untersuchung wurde weniger aufgeklärt. Korrelierend erinnerten sich rund 92 % aller Patienten nicht an eine Information über alternative Untersuchungsmöglichkeiten. 88,7 % der Patienten und 95,3 % der ärztlichen Teilnehmer befürworteten die Aufklärung mithilfe von interaktiven Videos und Animationen und 74 % der Patienten sowie 98,8 % der Ärzte die Beantwortung der Fragen zum Gesundheitszustand am Tablet/PC.

Schlussfolgerung

Die Dauer einer CT-Aufklärung wurde von den Patienten etwas kürzer eingeschätzt, wobei sich die Patienten teilweise nur schlecht an die Aufklärungsinhalte erinnerten. Die Akzeptanz gegenüber technischen Neuerungen war bei den Teilnehmern sehr hoch. Durch den Einsatz von Informationsvideos und Tablets/PCs könnte der Aufklärungserfolg erhöht werden.

[Analysis of documented informed consent forms for computed tomography : Completeness and data quality in four clinics]

BACKGROUND

Before performing a medical procedure, such as a computed tomography, an obligatory informed consent of the patient and its detailed documentation is necessary.

METHODS

A total of 1424 informed consent forms for contrast-enhanced computed tomography from four clinics with different healthcare levels were analyzed. Informed consent forms were evaluated related to completeness, legibility and quality.

RESULTS

In all, 1110 (77.9%) informed consent forms were sufficiently completed, 267 patients (18.8%) answered the form incompletely and 47 patients (3.3%) returned it without answering a question. Handwritten comments were found in 1391 (97.7%) cases. Thereof, 1329 (93.3%) were graded as detailed comments and 62 (4.4%) as less detailed comments. These comments were well legible in 675 (47.4%) cases, 558 (39.2%) informed consents showed limited legibility and in 158 (11.1%) more than 50% of the comments were unreadable. Signatures were complete in 1374 (96.5%) informed consent forms.

CONCLUSION

The results show a better quality and documentation of informed consent forms for computed tomography obtained by radiology residents compared to radiological specialists. Compared to the radiologists, the non-radiologists performed significantly worse. The establishment of videos and use of digital informed consent forms could provide a possible solution.

Visual differentiation and recognition memory of look-alike drug names: effects of disfluent format, text enhancement and exposure time

Three computer-based experiments were conducted to examine whether disfluent format, enhanced text, and increased exposure time improve the accuracy of visual differentiation and recognition memory of look-alike drug names. A three-way, repeated-measures look-alike drug name differentiation test assessed the visual differentiation accuracy of 30 nursing students (Experiment 1) and 15 nurses (Experiment 2). A two-way, repeated-measures recognition memory test examined the recognition memory accuracy of 15 nurses for look-alike drug names (Experiment 3). We found that making drug names disfluent did not significantly improve differentiation (Experiment 2) or memory accuracy (Experiment 3), but even impaired differentiation accuracy (Experiment 1). Enhanced text and longer exposure time significantly improved differentiation accuracy (Experiments 1 and 2). However, the enhanced text did not improve recognition memory (Experiment 3). We suggest that making look-alike drug names disfluent is not favourable. Enhanced text and longer exposure times are effective in supporting visual differentiation of look-alike drug names. Practitioner Summary: Confusion arising from look-alike drug names may compromise patient safety. Three experiments examined the effects of disfluent format, text enhancement and increased exposure time on visual and memory performances. Making drug names more difficult to read did not improve performance. Enhancing text design and increasing exposure (i.e. reading) time improved visual differentiation between medications, but did not improve the recognition of medications from memory. Abbreviations: SEEV: Salience-effort-expectancy-value; FDA: Food and Drug Administration; ANOVA: analysis of variance; SD: standard deviation, DF: disfluent format; TE: text enhancement; ET: exposure time.

A content analysis of documentation on communication disability in hospital progress notes: diagnosis, function, and patient safety

Objective:

To examine the content, quantity, and quality of multidisciplinary team documentation of ‘communication’ in hospital progress notes of patients with communication disability, and to explore the relationship of this documentation to patient safety.

Design:

Retrospective chart review involving a descriptive analysis and a qualitative content analysis of the progress notes.

Setting:

Acute medical and rehabilitation wards in two regional hospitals in one health district in Australia.

Participants:

Eight patients with communication disability who had experienced documented patient safety incidents in hospital.

Methods:

In total, 906 progress note entries about communication during 38 hospital admissions were extracted from eight patient’s charts; written by staff in 11 different health disciplines. Data were analysed descriptively according to quantity, and qualitatively according to the content.

Results:

Four content categories of meaning in progress note entries relating to communication were (1) use of communication diagnostic and impairment terms; (2) notes on the patient’s communicative function; (3) reports of the topic or content of the patient’s communication attempts; and (4) references to third parties communicating for the patient. Communication-related information was often brief, unclear, and/or inaccurate. Descriptions of communicative function and recommended strategies for successful communication were often lacking.

Conclusion:

The suboptimal documentation of patient communication in progress notes may contribute to the higher risk of patient safety incidents for hospital patients with communication disability. Increased accuracy in documenting communication disability and function in progress notes might assist staff in communicating with these patients and improve the quality and safety of their care.

Color-coding and human factors engineering to improve patient safety characteristics of paper-based emergency department clinical documentation

OBJECTIVE

Investigators studied an emergency department (ED) physical chart system and identified inconsistent, small font labeling; a single-color scheme; and an absence of human factors engineering (HFE) cues. A case study and description of the methodology with which surrogate measures of chart-related patient safety were studied and subsequently used to reduce latent hazards are presented.

BACKGROUND

Medical records present a challenge to patient safety in EDs. Application of HFE can improve specific aspects of existing medical chart organization systems as they pertain to patient safety in acute care environments.

METHODS

During 10 random audits over 5 consecutive days (573 data points), 56 (9.8%) chart binders (range 0.0-23%) were found to be either misplaced or improperly positioned relative to other chart binders; 12 (21%) were in the critical care area. HFE principles were applied to develop an experimental chart binder system with alternating color-based chart groupings, simple and prominent identifiers, and embedded visual cues.

RESULTS

Post-intervention audits revealed significant reductions in chart binder location problems overall (p < 0.01), for Urgent Care A and B pods (6.4% to 1.2%; p < 0.05), Fast Track C pod (19.3% to 0.0%; p < 0.05) and Behavioral/Substance Abuse D pod (15.7% to 0.0%; p < 0.05) areas of the ED. The critical care room area did not display an improvement (11.4% to 13.2%; p = 0.40).

CONCLUSIONS

Application of HFE methods may aid the development, assessment, and modification of acute care clinical environments through evidence-based design methodologies and contribute to safe patient care delivery.

Accuracy, legibility, and content of consent forms for hip fracture repair in a teaching hospital

OBJECTIVE

The purpose of our study was to assess the accuracy, legibility, and content of consent forms for hip fracture surgery in elderly patients.

METHODS

We performed a retrospective review of 116 patients older than 65 years who underwent surgical correction of hip fractures at a major US teaching hospital in 2005 and 2006. Accuracy was assessed by comparing the description of the operative procedure on consent forms and in electronic patient records. Legibility of consent forms was assessed with the Legibility Index. Content of consent forms was assessed with a complication score and the Crawford-Beresford-Lafferty score. Content of the operative procedure section on consent forms was further checked for readability using the Flesch Reading Ease score and the Flesch-Kincaid Grade Level.

RESULTS

Consent forms had a mean ± SD Legibility Index score of 3.4 ± 0.5. The mean complication and Crawford-Beresford-Lafferty scores were 8.0 ± 2.1 and 4.4 ± 0.7, respectively. With regard to operative procedure section readability, the mean Flesch Reading Ease score was 32.4 ± 18.4, and the mean Flesch-Kincaid Grade Level was 13 ± 3.1.

CONCLUSIONS

On the basis of the results, we found that consent forms for hip fracture surgery at this hospital were accurate in describing operative procedures. Consent forms were legible but written at high reading grade levels and were deficient in including all possible complications related to hip fracture repair. In conclusion, medical documentation and the informed consent process for hip fracture surgery in the elderly can be improved.

Auditing psychiatric out-patient records

PURPOSE

Up-to-date patient records are essential for safe and professional practice. They are an intrinsic component for providing adequate care and ensuring appropriate and systematic treatment 2009 plans. Furthermore, accurate and contemporaneous notes are essential for achieving professional standards from a medico-legal perspective. The study's main aim was to investigate current record-keeping practices by looking at whether out-patient communication pathways to general practitioners, from letter dictation to insertion in the chart, were being satisfied.

DESIGN/METHODOLOGY/APPROACH

From current out-patient attendees over six months, 100 charts were chosen randomly, and reviewed. A pro-forma was used to collect data and this information was also checked against electronic records.

FINDINGS

Of the charts reviewed, 15 per cent had no letter. If one considers that one-month is an acceptable time for letters to be inserted into the chart, then only 11 per cent satisfied this condition. Electronic data were also missing.

RESEARCH LIMITATIONS/IMPLICATIONS

It is impossible to discern whether letters to GPs were dictated by the out-patient doctor for each patient reviewed. Another limitation was that some multidisciplinary hospital teams have different out-patient note-keeping procedures, which makes some findings difficult to interpret.

PRACTICAL IMPLICATIONS

The review drew attention to current record-keeping discrepancies, highlighting the need for medical record-keeping procedures and polices to be put in place. Also brought to light was the importance of providing a workforce sufficient to meet the out-patient team's administrative needs. An extended audit of other medical record-keeping aspects should be carried out to determine whether problems occur in other areas.

ORIGINALITY/VALUE

The study highlights the importance of establishing agreed policies and procedures for out-patient record keeping and the need to have a checking mechanism to identify system weaknesses.

Improving the Quality of the Order-Writing Process for Inpatient Orders in a Teaching Hospital

BACKGROUND

Physicians' illegible handwriting is a notorious contributing factor to medical errors. Furthermore, an illegible signature or failure to print prescribers' name interferes with the ability of staff to clarify orders.

METHODS

We surveyed support medical staff at a teaching hospital before and 2 months after providing all internal medicine department residents a self-inking stamp with their name and pager number.

RESULTS

Responses were received from 51% at the first and 36% at the second survey of 401 eligible staff. Responses to questions regarding illegible or absent signature, illegible or absent pager number, and failure to print prescribers' name showed a significant improvement (P < .0001) after 52 residents working in the hospital started to sign orders with their stamp. The support staff also noted a significant reduction in the time required to contact a physician to clarify orders, from more than 10 minutes to 1 to 5 minutes (P < .0001).

CONCLUSION

Physicians signing orders using a stamp with their name and pager number provide support staff legible identification, leading to an improvement in the quality of the order-writing process. This kind of signature allows clarification of orders in a timely fashion.

Practice ordering guidance for neonatal parenteral nutrition

OBJECTIVE

Neonatal parenteral nutrition (PN) is designed for very low birth weight infants (BW < or = 1500 g) for whom enteral feedings are inadequate. Evaluating the clinical practice guidance (CPG) content of printed paper order forms could provide a baseline for comparison and serve as a reference for electronic neonatal nutrition order design systems.

METHODS

A scoring system for clinical practice guidance was developed and applied to nine institutions printed paper PN order forms. CPG scores were assigned as: (1) generic reminder only, (2) prompt with order entry space, (3) patient specific reminder only, (4) patient specific recommendation with order entry space. User-friendliness and form completion time were also recorded.

RESULTS

The overall CPG score for the six most common PN components was 1.85+/-0.68 (mean+/-1s.d.), consistent with a generic reminder, but short of a specific nutrient dose order field. Amino acid received the highest CPG score, 2.05+/-0.64; vitamins rated the lowest. The institution of origin was an independent predictor of the CPG score.

CONCLUSIONS

Paper neonatal PN order forms offer relatively little CPG. Significant form variation and format reflects the need to standardize neonatal PN design as the neonatal PN design moves from paper to electronic ordering systems.