How to Interpret Doctors' Writing
Instructions
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Scan the chart, script, or other written materials to check the overall legibility of the doctor's handwriting. Start with critical sections to find text that you can and cannot readily read.
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2
Read the notes or text in question line by line to gain overall meaning. Pause when you encounter words that you cannot make out.
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3
Spell out the incomprehensible words as best as possible. Begin to mentally decode each word by looking at the number of letters in the words and at the positions of any recognizable letters.
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4
Use your knowledge of medical terminology and medical abbreviations to consider just what these words might be. Think about what you know about roots, prefixes and suffixes that can help you decipher the cryptic handwriting. Refer to a medical dictionary, such as one from the National Institutes of Health, to check your hunch.
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5
Search for medical keywords. Look at the wording to see how unknown words relate to them in the surrounding context. Use your medical background to figure the meaning from the context by inserting words that make sense. Look for familiar terms that can impart meaning to the surrounding words.
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6
Examine numbers that can indicate quantity, duration or dosage. Use your knowledge of treatment regimes, procedures and medications to decipher any figures.
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7
Piece together the parts of the text that you can definitely read and use your general medical knowledge to fill in the meaning. Once the meaning is grasped, the handwriting will become clear.
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8
Get assistance from other staff, colleagues or associates to help you read the questionable handwriting. They may help with words you don't know, or convey information about a special way a particular doctor abbreviates certain words.
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9
Ask the doctor who wrote the order to tell you exactly what it says. Page or visit with the attending doctor to find out the missing text so you don't end up harming any patients.
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