Medical records, Written documents, Legible, Medical Council registration number (MCRN), Clear signature,
Objectives Good medical records ensure continuity of care.
Doctors must ensure that written documents are legible and make their signature clear, adding their Medical Council registration number (MCRN). This is also a new requirement under Section 43 (8) of the Medical Practitioners Act (Ireland, 2007). The aim of this study was to examine (i) the legibility of Doctors’ handwriting, (ii) the use of signatures and (iii) the inclusion of the MCRN after each chart entry.
Methods A random sample of 85 medical maternity charts was examined. Entries from antenatal clinic visits, inpatient and postnatal sections were taken from each chart, and copied to preserve anonymity. All entries were examined to establish if the doctor had signed and/or printed their name, and entered their MCRN. Finally,
100 entries were randomly selected and a legibility scoring system was applied. Entries were scored from one to four according to illegible words and ease of reading, by separate reviewers (a medical secretary, a midwife, a junior and senior obstetrician).
Results We found that <10% of doctors were printing their names after antenatal clinic entries, while half were printing their names after entries in inpatient notes. Only 8% of doctors wrote their MCRN in antenatal clinic entries, 35% in inpatient notes and 38% in postnatal notes. In terms of legibility, of the 100 samples gathered, 6% scored ‘one’ indicating that the writing was completely illegible, 33% scored a ‘two’, meaning that some words were legible but the note was still not legible. The remaining 61% scored either a three or four meaning that they were completely or almost completely legible.
Conclusions Good record keeping should be an integral part of good medical practice. In contrast, the majority of doctors are still not signing their name with their accompanying MCRN number and almost 40% of notes examined in this sample were illegible