LEGIBILITY AND COMPLETENESS OF PHYSICIANS HANDWRITTEN MEDICATION ORDERS

OBJECTIVE: To assess handwritten medication orders for legibility and completeness, legibility of physician signatures, and presence of date and time the orders were written. DESIGN: Descriptive. SETTING: Three patient care units in one hospital in Texas. SAMPLE: One hundred seve nty-six medication orders and 55 signatures by 36 different physicians for 39 patients. METHODS: Six experienced nurses evaluated medication orders and signatures for legibility using a rating scale developed f or the study. Completeness of medication orders and presence of date a nd time were determined. RESULTS: Twenty of the medication orders and 78% of the signatures were illegible or legible with effort. Twenty-fo ur percent of the medication orders were incomplete. Date was omitted on 18% of the medication orders, and time was missing on 58%. CONCLUSI ON: Difficult-to-read and incomplete medication orders continue to be an important system problem that can increase risk for medication erro rs and patient harm. Good penmanship and complete orders are unrealist ic goals without system support.