"What’s that word?" …
"No, not that word… THAT word." …
"Look like twice? Err… maybe toast?"
Does this scenario sound familiar to anyone? “Dr. Cursive” just wrote an order and it’s your job to
interpret the results note the orders.
By noting the orders you’re verifying their presence, following all policies and procedures, doesn’t violate any laws, not contraindicated for that particular patient, follows the 7 rights of medication administration, etc, etc.
The problem is. You’re not exactly sure what you’re reading. (It’s English right? )
You did take the ‘hieroglyphics’ class in school didn’t you?
We are taught that if it’s illegible, or there is a question regarding the order, we are to call the physician to clarify. (Yeah.. that goes over like a lead balloon)
Here’s the problem.
We nurses love to point the finger and rat out ‘that physician’. In some hospital systems the physician get a 2 strike warning. After the second notice, if they have not improved their hand writing skills, they are required to attend a formal class on hand writing etiquette! (No I did not make that up)
What about our fellow nurses who do the same thing? Ever follow a nurse after change of shift and try and review their narrative note… And realize that we nurses create our own type of hand writing communication in the form of broken-words, run-off one syllable sounds, and abbreviations that JCAHO would have a heart attack reading.
It’s funny, and if you’ve experienced this I know your chuckling inside. Hell, I’m one of the hieroglyphic-guilty charting fools. My handwriting is atrocious. Even I have a difficult time reading my own hand writing.
It’s also not funny. It’s a down right serious problem. The potential for error and questionable practice is literally smacking you in the face.
Patient safety walks shoulder to shoulder with patient advocacy, and if we don’t chart properly and legibly we put our patients at risk.
I wrote this blog to give myself a wake up call.
Chart legibly. Even if the doctors don’t.