Can you identify at least 6 contributing factors to cacography depicted in this photo?


Published 5/1/2011
John M. Purvis, MD

Do you have cacography?

It’s not contagious, but it is dangerous

Has your office been swamped with phone calls from pharmacists and nurses to clarify a prescription or your hospital orders? Ever added up your golf score wrong or needed help reading your own notes? Then you might have cacography. It’s not contagious, but it can cause damage, and in some states, it’s actually illegal. Thankfully, you’re not alone and the condition is treatable.

Cacography is bad handwriting. It derives from the Greek graphos, “writing,” prefixed with kakos, “bad,” and contrasts with calligraphy. Cacography is not a new word, or a new problem. By reputation, doctors have it, but so can nurses and nonmedical folks. In medicine, however, the stakes are often higher. An illegible business report has different consequences than an unreadable past medical history or drug allergy report on a comatose patient. Bad handwriting has always been, and will remain, a problem in medicine.

Medical handwriting horror stories are legion. Cacography is often a cause of medical errors, litigation liability, and significant waste in medical care. According to the Agency for Healthcare Research and Quality, poor penmanship is responsible for an estimated 6 percent of all hospital medication order errors. Healthcare professionals could better spend their time delivering patient care than trying to decipher illegible entries in the medical record. Lost revenue may result from errors or omissions due to unreadable entries in the medical record.

Regulatory agencies such as the Joint Commission place a high value on legible medical records. Standards requiring the review of medical records for legibility have been developed. Hospital medical staffs are required to assume a leadership role to improve performance in measuring and requiring legible medical records. But it is not the rules and regulations that are important—it’s patient care and safety.

From decade to decade, the emphasis on handwriting competence has decreased. Most Americans don’t receive any formal handwriting instruction beyond the third grade. A little training in parallel downstrokes, efficient pen paths, and nonjoined letters, however, can improve both writing speed and legibility.

Computerized physician order entry and electronic health records may eventually replace handwritten charts and prescriptions. Writing a prescription or clinic note (to think in ink) may seem tedious following the cognitive efforts of reviewing a patient’s history and exam, and then verbalizing the diagnoses and treatment plans. But doctors will always need to write, and their writing will need to be understood by others—even if it is just on a stick-on note.

If hospital personnel, pharmacists, or your peers have diagnosed you with cacography, please seek treatment. It will be for the good of your patients. Be understanding if you get phone calls for clarification. Some reasonable and relatively painless treatment options follow. If you know of others, please write me a letter—or on second thought, send me an e-mail instead.

Treatment options for cacography

  • Optimize your posture for relaxed writing; sit down if possible.
  • Use an adequate surface area with support for your hand and forearm.
  • Take the page out of the ring binder or folder and lay it flat.
  • Use an assistant as a scribe.
  • Use well-designed forms and templates for progress notes and chart documents that require minimal handwriting.
  • Maximize use of electronic records.
  • Print if that is more legible than your cursive style.
  • Take handwriting lessons to increase legibility, fluency, and speed.
  • Reduce hand pain by using a well-fitted writing instrument.
  • Slow down; writing legibly takes time.
  • Write larger—if the paper has narrow lines, write on every other line and don’t try to cram words into tight spaces.
  • Use identification numbers with your physician signature and consider purchasing and using a self-inking name stamp or pen.
  • E-prescribe; use computerized physician order entry and electronic records.
  • Review your written orders verbally with the nurse or clerk on the floor.
  • If all else fails, dictate instead. Speech recognition software has improved substantially.

John M. Purvis, MD, is a member of the AAOS Now Editorial Board. He can be reached at