Handwriting in the medical record can be graded based on a legibility score used by Berwick and Winickoff. Poor penmanship is a major source of avoidable medical error.
Features of Record
Score
illegible with most or all words impossible to identify
1
most words are illegible and the meaning of the report is unclear
2
some words are illegible but the report can be understood by a clinician
3
legible with all words clear
4
Interpretation:
• The lower the score the more serious the problem.
Limitations:
• The extent (single sentence, a paragraph, an entire record) of the text evaluated can impact the scoring.
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