It doesn’t violate HIPAA if it’s illegible

I love A Cartoon Guide To Becoming A Doctor. Love isn’t even a strong enough word. Maybe if I capitalize it, and put some exclamation points after it. LOVE!! IT!!

When I read this post of hers, complaining about an illegible note in a chart, I giggled and felt a little illicit. I fight the urge to ever use my camera phone in my training at all. I know people who have taken pictures of sutures, fibroids, etc. I was told to take a picture of an abdomen with scabies excoriations on it (that I did an exam on without gloves…ugh), and I didn’t. I may have an overdeveloped sense of patient rights, but taking pictures like those just creeps me out.

But, I totally get taking the photo of the illegible note now. First of all, it doesn’t involve any patient body parts. Second of all, there is no identifiable information. Third, if you can’t read a friggin’ word of it, there is absolutely no value to it at all, except to mock it.

So, here are two consecutive notes in the chart of a patient I was following last week.
illegible note 1
illegible note 2

Any guesses as to what sort of progress this patient made? How about the specialty of the physician writing the note? I’ll give you a hint, there was a surgery involved. Sorry it’s a little blurry, but trust me, it wasn’t any easier to read in person.


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14 responses to “It doesn’t violate HIPAA if it’s illegible

  1. Would help to know why the patient was in the hospital. However, I’ll take a crack at some of it. Top picture, 2nd written line, “reg” (regular) something; 4th line says something about “a.m.”; 5th line almost looks like pnv, but I don’t think that’s it (but it makes me think “prenatal vitamins” or something about nausea and vomiting). Bottom picture, first line: something happened at 6 a.m.; the rest of it – beyond even a guess.

  2. MomTFH

    The patient had a kidney removed. The only thing I am sure of is that the first line says “G.U.”, or genitourinary. I think the third line under the G.U. on the first one says “ab: soft”, indicating that the abdomen was soft. The next line may be an up arrow, then DNT, which may stand for increased distention, not tender. I think the line under that says di tomorrow, saying it would be OK to discharge tomorrow.

    The next note…I have no clue.

  3. Fizzy

    Sorry, I can’t read Chinese 😛

    I was super careful about the post, before I made it. I made sure I cut out anything that could possibly identify the patient, doctor, hospital, or anything. I’m fairly sure even the greatest detective in the world couldn’t glean any real information from that post I made 🙂

  4. Phledge

    This is a travesty bordering on criminal neglect. What the fucking fuck? Does this doc REALLY want a nursing call at three am?

  5. This is awful! I hate when there is a consult in the chart and I have no idea what it says..what the note above says I have no idea. I had one doc who just put extra loops in things for the heck of it. Do the docs at your hospital get fined for bad handwriting? Ours do..but it doesn’t change anything.

  6. medrecgal

    Holy chicken scratch!! This kind of post makes me grateful for our use of an EMR; for all its limitations, we can always read what a provider types into the chart. (Though I’ll be the first to admit that understanding can still be limited by the quirks of the reader’s brain, LOL!) This problem is not limited to physicians, however…I have seen my share of illegible writing in several different places. It says some rather f-ed up things about our society when this kind of “documentation” is thought by some to be acceptable. (Not in *my* arena, however; we’d probably have to get in touch with this person to find out just exactly WTF (s)he wrote if we worked with paper records.)

  7. Ha! I’m glad I’m not the only one who gets riled up about this.

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  9. We get this kind of crap at the pharmacy where I work too. I’m all for making HCPs key this kind of stuff into a computer program of some sort.

  10. The purpose behind the record is to provide information to other current and future providers, as well as the patient, about the treatment and progress of care.
    EMRs definitely go a long way to improving this and other issues that can get in the way of better outcomes.
    We’re working on balancing technology, usability, and affordability with our new system for midwives.

  11. Naomi

    I worked for a few years as an office manager for a computer technician. His handwriting was HORRIBLE. I spent countless hours comparing letters in different notes so I learn his version of the alphabet. By the time I left, his wife said I could read his writing better then she could, but that took a LOT of effort!

  12. I HATE reading doctor’s notes in the paper charts. It’s amazing we can figure out what to do with the patients after their chicken scratch.

  13. Susan Peterson

    There was a doctor where I worked as a nurse who wrote posts like this. He was “written up” for illegible notes and orders many times but it didn’t change him. It is amazing what we did learn to read!

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