Description

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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