Legibility of physician handwriting is an issue in every hospital. Nearly every medical record I have ever reviewed—more than 100,000 in my lifetime—has had at least one illegible note. Some have been completely illegible. Many of the accrediting and government agencies have created sanctions or fines for hospitals with illegible medical records. In the meantime, what can you do if you obtain your medical record and cannot read it?
First, under the federal law known as HIPAA, you have the right to request a correction in your medical record if you believe the information is incorrect, inaccurate, or incomplete. If you cannot read the information in your record (due to illegibility), you can file a request for correction with the hospital asking that the author of the illegible information rewrite it so you can read it. This is a reasonable request. And, if more patients exercised this right, maybe more physicians would provide legible documentation. The downside to this approach is that it may take several days or weeks for the physician to document the information you are requesting.
Second, if you want more immediate results, you can seek help reading the illegible record from several experienced individuals, including staff in the hospital’s HIM department, another clinician, or even the physician who created the record.
Lastly, you may want to consider sending a letter, along with copies of the illegible information (minus your identification information), to the hospital administrator. Providing this feedback may help not only you in your current predicament, it may help ensure that future documentation is legible.
Ruthann Russo, PhD, JD, MPH, RHIT, is a healthcare expert with more than 20 years of experience working in and advising healthcare organizations.
