The long and short of IT
“60Y/F, CC: FOOSH, pain LDR, Ph: DM, HTN, PTCA, Δ: #LDR, Rx: ORIF under GA.”
Sometimes I cannot read my own handwriting, that is a problem
- Judy Blume
Probably looks like gibberish to most people. An orthopedic surgeon will make complete sense of it in a few seconds.
Translation: A 60-year-old female came with chief complaints of a fall on the outstretched hand and pain left distal radius. She has a previous history of diabetes, hypertension, and underwent coronary angioplasty. Diagnosed with a fracture of the left distal radius. Planned treatment is open reduction internal fixation under general anesthesia.
Doctors are notorious for their illegible handwriting. One of the aspects of our day-to-day practice that we are focusing on improving is legible handwriting and avoiding abbreviations.
“When I was in primary school my handwriting was so bad, that my teacher told me I would grow up to be a doctor, my fate was sealed”
- An Australian G.P.
If you compare the medical profession with other professions, like law, which involves copious amounts of writing, doctors may not be that far behind in the legibility factor. I just feel that our prescriptions are more in the public domain for scrutiny. Not to justify anything here.
Medical terminology is a different language for most of us. Once you start medical school, it is like learning a new language, with roots in Greek and Latin. The words themselves push us towards illegible handwriting, to mask many spelling errors that tend to creep in. Imagine writing choledocholithiasis, even with the spell checker working in the newer computers, you are likely to get it wrong. Medical terminology is filled with such alien words for the modern English speaker.
Rx, a symbol on pharmacies and doctors' pads, might have originated as a stylized form of the symbol of the “Eye of Horus”, which was an Egyptian symbol for healing power. The other explanation being a stylized form for the word recipe. The first recorded prescription dates to 2100 BC from Mesopotamia. The earliest known pharmacy or apothecary dates to the 8th century AD, established in Baghdad. When doctors used to prescribe medication, it would be individualized and prepared specifically for that person, hence the word recipe. This used to happen till the 1950s after which the mass production of drugs took off. Coca-cola was invented by a pharmacist, John Pemberton, who initially marketed it as a cure for many ailments.
Only the pharmacist needed to understand what was on the paper and there were clear instructions on how to prepare medication along with dosages. There is also a myth that such illegible handwriting evolved from a need to keep secret, from the patient, what was being prescribed. Some of the terms needed to be understood by the pharmacist, which may look like kids scribble to you. For example, TID is the shorthand for the Latin phrase which “means three times a day.” The pharmacist would then guide the patient on how to take the medication. Nowadays, using the traditional Latin phrases is being discontinued so that the patient also understands what has been written.
This habit of writing illegibly and using short forms goes hand-in-hand. Thirty years ago, during our clinical rounds, as part of our training for the exams, we would be given what we would call a long case. We had 45 minutes to talk to and examine a patient and present the same to a professor, with a diagnosis and findings to substantiate the case. Time was of the essence. We would leisurely take the patient’s history and examine the patient and use as little of the allotted time as possible to write it down. Imagine the writing and the short forms that would creep in. If we missed elucidating a finding during the presentation and the professor raised a query regarding the same, the notes were the evidence that we had thought of it but slipped to mention it. So, the notes had to be exhaustive at the same time.
In day-to-day practice, and with all the medicolegal implications, the dictum is, if it is not documented, it did not happen. No matter how busy the doctor, he will not be pardoned if he did not document what was done. Scribbling something on a piece of paper that is akin to what was done has found acceptance. Imagine writing pseudopseudohyperparathyroidism, would not it be easier to write it down as PPHP. It is not only convenient, saves time and spelling errors can be avoided. Even the modern spell checkers will show most medical jargon as errors. The longest word in my knowledge is a medical word: pneumonoultramicroscopicsilicovolcanoconiosis.
Significant problems also arise, due to these short forms, which are not standardized. These are also influenced by local and cultural factors. They can be even more ambiguous when spoken and not written.
During patient rounds
Prof: Could you get BT and CT done for this patient.
Intern (1st day): Sure.
The next morning with a smug smile on his face the intern shows Computed tomography films and informs him that the blood transfusion had been completed.
An angry Prof: I had asked you to get the bleeding time and clotting time done!
Spell checker in word, suggests that “British Telecom” be substituted for BT.
I can quote many such examples, where mistakes have been innocuous to downright dangerous to the patient. There is a constant push by quality-conscious hospitals and doctors to make doctors' handwriting better, short forms are to be avoided and medication to be written in capitals only, verbal orders need to be informed to two other persons at least and countersigned within 24 hrs. Although shifting to EMR (Electronic Medical Records) has changed drastically the legibly the aspect, short forms remain the bane of many medical records.
It's a paradox, the new age lingo is littered with OMG, ROFL, LOL, and people make complete sense of them. As the world embraces, short forms, we doctors have just begun to learn to expand.