Medical Notes Translations: Deciphering Medical Doctors’ Handwriting

Medical Notes Translations Deciphering Medical Doctors Handwriting

Written by Bernadine Racoma

November 25, 2020

Have you tried reading the handwritten prescription from your doctor? Was it legible, and did you succeed in reading it?

If you believe what most people say, you’d think that all doctors have bad handwriting. But it’s not the case, as there are also many doctors whose writing is apparent and legible. One question remains, though. How come most doctors’ handwriting is difficult to read? There must be several reasons that contributed to this common belief.

Why do doctors have bad handwriting?

You need to get one thing straight. Not all people with bad handwriting are in the medical field. Many doctors will attest that they started out with good handwriting, which later developed into a scrawled script that is illegible to most people.

Here are some of the reasons that doctors give as to why their handwriting has become difficult to decipher.

1.  They take down a copious number of notes

From the time they are at university, through internship all the way to medical practice, doctors have to write more than the usual since everything has to be documented. As doctors, the practice remains the same. Even the private discussion between a doctor and patient requires written evidence. Thus, things are recorded in the patient’s medical history.

Doctors work long hours, and they spend plenty of time writing notes. The small muscles on the hand are overworked, and they get tired.

2.  They are always in a rush

Doctors, particularly those working in hospitals, are busy most of the time, spending very little time between patients. They do not have a chance to rest their hands properly. Thus, they are more concerned with recording the patients’ medical information than the way they write.

While writing down the patient’s condition, the doctor has to use medical terms. Medicine has a huge collection of medical terms, many of which are difficult to spell.

3.  But, they make sure to write clearly when it matters

Doctors use abbreviations when they write out prescriptions. Pharmacists typically understand these symbols and abbreviations. However, doctors themselves are careful when writing prescriptions that may cause major consequences when misread. Today, most doctors write out micrograms instead of ”mcg” and milligram rather than ”mg.”

In a 2017 study that aimed to know how accurate professionals in the medical field could read medical prescriptions, the results revealed that:

  • 88% of the participating doctors read the prescriptions written by 20 other doctors correctly
  • 82% of the nurses read the prescriptions correctly
  • 75% of the pharmacists did not have trouble reading the prescription

What languages do doctors speak?

Doctors speak their native tongue when practicing in their own community. In the United States, many of the doctors speak English and Spanish. Across the United States, many doctors are multilingual. The top languages spoken by doctors aside from English and Spanish are French, Farsi/Persian, Chinese, Arabic, German, Russian, Italian, and Hebrew. Recently a study by a community of doctors included Hindi and Filipino among the most spoken languages.

However, most patient languages across the U.S. are Sub-Saharan African and Swahili, Near East Arabic and Hamitic, Polynesian, Southeast Asian and Burmese, Filipino, Korean, Indonesian, Vietnamese, Thai and Japanese.

With the linguistic discrepancy, Section 1557 of the Affordable Care Act (ACA) in the United States requires medical practitioners and medical institutions to provide language services (translation and interpretation) in the 15 most spoken languages in the locality.

What language do doctors write in?

Doctors and medical professionals who are involved in research and clinical studies write in medical English.

Almost every influential medical journal use English when publishing studies, reports, and other medical information. At international conferences, English is the language of choice. Today, the medical community has chosen a single language, English, for international communication.

In the past, medical Latin was de rigueur, with the newer medical terms using roots from Latin or classical Greek. Today, most medical terms are borrowed from English. For example, terms such as scanning, screening, base excess, clearance, and bypass operation, are adopted by some non-English speaking countries. Romania, Italy, Scandinavia, Germany, and the Netherlands, use the term bypass.

The term ”bypass” is ”pontage” in French, while Poland uses “pomostowanie.” These are local translations of the term, ”bridge.”

In Russia, they use the term “shuntirovanie,” which is an Anglicism, as it is derived from the English term, ”shunt” which means bypass or passage.

Doctors from non-English speaking countries choose to either use the medical terms in English or have them translated into their native languages.

The difficulty is in the use of acronyms, such as PCR (polymerase chain reaction), MR (mitral regurgitation), CT (computed tomography) or AIDS (acquired immunodeficiency syndrome) because the position of the letters changes when translated into another language. However, in most cases, these abbreviations are accepted, with some exceptions. In France and Spain, they use SIDA, while in Russia, they use SPID.

Do medical doctors use shorthand?

While it would seem that doctors use shorthand when writing reports and prescriptions, that is not true. What they are using are prescription abbreviations based on Latin words. The abbreviations tell the pharmacist about the medication a patient requires and how the medicine should be taken.

It is a good idea to learn these prescription abbreviations to ensure that you are given the right medication and understand how you should take your medicine. If you cannot decipher the handwriting, do not afraid to ask your doctor to explain the prescription or write down what condition the prescribed medication is for, i.e., the frequency and the specific condition, such as ”take every eight hours for fever.”

Here are some of the common prescription abbreviations you’ll find:

For frequency of dosage:

  • ad lib – as needed, freely
  • bid – twice a day
  • q – every
  • qd – every day
  • prn – as needed
  • q3h – every three hours
  • q4h – every four hours
  • tid – three times a day
  • qid – four times a day
  • qod – every other day

Time to take the medication

  • ac – before meals
  • pc – after meals
  • int – between meals
  • hs – at bedtime

Amount of medication to take

  • gtt – drops
  • cap – capsule
  • tab – tablet
  • tsp – teaspoon or 5 mL
  • tbsp – tablespoon or 15 mL
  • mL – milliliters
  • mg – milligrams
  • ss – one half
  • i, ii, iii, or iiii – indicates the number of doses, in 1, 2, 3, or 4

Using the medication

  • c, oro – with
  • s, orø – without
  • top – apply topically
  • sl – sublingual
  • po – by mouth
  • ou – both eyes
  • os – left eye
  • od – right eye
  • al – left ear
  • ad – right ear

Doctors may write the brand name of the medication, write the generic name, or both. In many U.S. states, pharmacists can legally dispense a generic medication instead of the branded medication written on the prescription.

However, if the doctor included the abbreviation “DAW” on the prescription, the pharmacist must follow what is written on the prescription. DAW means dispense as written, which instructs the pharmacists that they cannot substitute a generic brand with the prescribed brand.

The abbreviation “sig” that appears before the directions on the prescription means ”let it be labeled,” or “write on the label,” which is from the Latin term, signetur or signa.

Rely on eTS for accurate translation of medical notes

Precision and accuracy are critical to medical translations. At eTranslation Services, we only assign medical translations to our certified medical translators, with years of field experience behind them. With their experience, they have a deep understanding of the specific terminology used in the different branches of medicine, ensuring the accurate translation of your medical notes. Kindly get in touch with us through [email protected] or via (800) 882-6058, and let’s discuss your requirements for medical translation.

 

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