Related Experiment Video
Updated: Jul 31, 2026
12:08
Improving IV Insulin Administration in a Community Hospital
Published on: June 11, 2012
Legibility and completeness of physicians' handwritten medication orders
E H Winslow1, V A Nestor, S K Davidoff
1Presbyterian Hospital of Dallas, TX 75231, USA.
Heart & Lung : the Journal of Critical Care
|March 1, 1997
Summary
Handwritten medication orders and physician signatures are often illegible or incomplete, posing risks for patient harm. System support is crucial for improving legibility and completeness of these critical medical documents.
Area of Science:
- Medical Informatics
- Patient Safety
- Healthcare Systems Engineering
Background:
- Illegible and incomplete handwritten medication orders present a significant challenge in healthcare settings.
- Physician signature legibility and the accurate recording of date and time on orders are critical for patient safety and medication management.
Purpose of the Study:
- To evaluate the legibility and completeness of handwritten medication orders.
- To assess the legibility of physician signatures.
- To determine the presence of date and time on medication orders.
Main Methods:
- A descriptive study was conducted across three patient care units in a Texas hospital.
- 176 medication orders and 55 physician signatures were evaluated by six experienced nurses.
- A standardized rating scale was used to assess legibility, while completeness and the presence of date/time were systematically determined.
Main Results:
- A significant percentage of medication orders (20%) and physician signatures (78%) were found to be illegible or required considerable effort to read.
- 24% of medication orders were incomplete, with date omissions occurring in 18% and time omissions in 58%.
Conclusions:
- Poor legibility and incompleteness of handwritten medication orders represent a persistent system issue, potentially increasing the risk of medication errors and patient harm.
- Achieving legible handwriting and complete medication orders necessitates systemic interventions rather than relying solely on individual physician performance.
Related Concept Videos
01:30Guidelines for Nursing Documentation I
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:26Guidelines for Nursing Documentation II
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:26Methods of Documentation II: POMR
The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
01:18Guidelines and Strategies for Safe Computer Charting
The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Maintain Confidentiality and Security:
01:26Types of Reports III: Telephone and Verbal Reports
Telephone and Verbal Reports in healthcare settings are two communication methods for conveying therapeutic instructions from healthcare providers to nurses or other healthcare staff.
Here's an overview of each type:
Telephone Orders
Here's an overview of each type:
Telephone Orders
01:06Legal Guidelines for Documentation
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here: