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
illegible with most or all words impossible to identify
most words are illegible and the meaning of the report is unclear
some words are illegible but the report can be understood by a clinician
legible with all words clear
• The lower the score the more serious the problem.
• The extent (single sentence, a paragraph, an entire record) of the text evaluated can impact the scoring.
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Purpose: To evaluate the legibility of a medical record using the legibility score of Berwick and Winickoff.
Objective: other testing, severity, prognosis, stage