Legal perspectives
From a legal perspective hand written records can present the greatest challenges where these are viewed as the only record of the care provided to a patient/client. Handwritten records need to be clear and unambiguous. Failure to keep clear records can give rise to the professional being found negligent in their care. In Prendergast v Sam and Dee (1989) where an illegible prescription resulted in a patient being dispensed the wrong drug resulting in harm the court held that:
'it was the duty of the doctor to write clearly and legibly so that anyone could read this without misunderstanding or making a mistake'
The court found that both the G.P. who wrote the prescription and the pharmacist who dispensed the drug wrongly where negligent in the delivery of their duty of care. In this case the court held that the Dr was 25% liable for the patient harm in that he did not write a readable prescription and the pharmacist was 75% liable in that he could not read the prescription clearly and dispensed the wrong drug.
