Important Measures to Improve Legibility

Friday, May 03, 2013 at 3:16:43 PM

Medical Executive Committee agreed that legible block letters should be used by physicians identified by audit as having illegible orders. A letter will be sent to those physicians explaining the recommended approach. Please take care to provide legible orders and ensure appropriate and timely patient care. If staff is unable to read an order, the physician will be contacted to clarify.
Signatures are used to identify the providers' documentation. If they are unable to be read, providers will be asked to do one of the following: use block letters to also write your name, use a stamp with your name (ex: Robert Smith, DO), or write your physician number next to your signature. This will allow the Joint Commission and CMS to identify who the provider is for that documentation.
As always, your cooperation and collaboration is appreciated! Signatures for all orders need to be completed within 48 hours. The flags are placed in the record on a nightly basis and any provider caring for that patient should review all of those flags for items needing signature, date, and time. Please be sure to review these and complete them on a daily basis. Providers on a care team can sign for one another on orders.
For any providers that are interested in improving their handwriting, you can work with an expert to help. You can also have specific forms developed to allow for more checkboxes and less handwriting. If you are interested in the stamps, handwriting assistance, or preprinted forms, please contact Nancy Gaska at nancy_gaska@uhs.org or (607)763-6202.

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