In the context of medical documentation, what does 'legible' refer to?

In the context of medical documentation, 'legible' specifically refers to the clarity and ease with which written information can be read. Legibility is crucial in healthcare settings because it directly impacts patient safety and the accuracy of care. If medical records, prescriptions, or notes are difficult to read, it can lead to misunderstandings, medication errors, or miscommunication among healthcare providers, which could have serious consequences for patient care.

While descriptive accuracy and adherence to coding standards are vital for thorough documentation and compliance, they do not pertain to the concept of legibility. Similarly, using language that is understandable to the patient ensures effective communication but does not address the visual clarity of the written text itself. Legibility primarily emphasizes how easily someone can decipher the handwritten or typed documentation.