# illegible records



## dsmith06351 (Sep 15, 2009)

I am not an auditor but occasionally will audit our doctors charts to check on the level of their E/M services. We have 2 doctors whose handwriting in illegible, being an employee I can figure what most of it says and ask the doctors to fill in the blanks. My question is if an auditor came into the office and audited these same records how would they handle the illegible records.

Thanks for any help,

Denise Smith CPC-A


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## Anna Weaver (Sep 15, 2009)

dsmith06351 said:


> I am not an auditor but occasionally will audit our doctors charts to check on the level of their E/M services. We have 2 doctors whose handwriting in illegible, being an employee I can figure what most of it says and ask the doctors to fill in the blanks. My question is if an auditor came into the office and audited these same records how would they handle the illegible records.
> 
> Thanks for any help,
> 
> Denise Smith CPC-A



We have a 2 person rule, if 2 people can't read it, it doesn't count. Sometimes we will allow the office to do a transcription of the visit. Depending on if the physician is still with us, if the physician is still availalbe for clarification.

Here's an article I found concerning this:
http://www.hcpro.com/CCP-31725-862/...e-OIGs-pharma-guidance-affects-providers.html

What can we do about illegible physician handwriting? 



Q: As part of our ongoing record review, we are monitoring legibility of handwritten entries in medical records. What would be the appropriate process to follow when addressing legibility of a physician's handwriting? I would like to have some options for corrective action when I approach the medical staff with this issue. 

A: Hospitals that allow handwritten notes must develop standards on how to address physician handwriting. Establish a procedure if hospital staff can't read a chart. For example: If legibility problems arise, physicians must be available within a certain time frame to either dictate or re-write a note for clarity. 

According to medical documentation guidelines, if a chart note was not documented, the service was not done. That's also true if the chart is illegible and a CMS (Centers for Medicare and Medicaid Services) auditor can't read it. Since a physician's notations in the medical record are an important part of treatment, illegible notes create a serious problem for all health care providers who need the information for follow up care. 

Some organizations are switching to electronic medical records (EMR) to avoid these, and other problems, including the legibility issue. EMRs also help to reduce process and patient errors due to illegible or incomplete notes. However, EMRs are expensive and take years to implement. 

If workers are repeatedly asking physicians to rewrite notes, hospital administration and/or the applicable medical staff committee should meet with them to review the problem and assess remedies. If, even after education or other corrective action measures, physicians continue to produce illegible medical records, it could be an indication that you have an ineffective compliance program. 

Set up a policy so physicians are clear that if they fail to improve their legibility, you could terminate them from the medical staff. This is rare, but you can avoid it through education, collaborative dialogue, and automated resources, like EMR and dictation services.


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