Tips for getting an accurate reading level score

Make simple changes to copy while calculating

While many factors determine whether patients will understand written material, their ability to read the piece is fundamental. Therefore, copy must be written at an appropriate reading level.

Readability formulas offer a way to evaluate the reading grade level of a document. These formulas look at the number of syllables in a word, the number of words in a sentence, and the number of sentences in a paragraph, says Doug Seubert, guideline editor in Quality Improvement and Care Management at Marshfield (WI) Clinic.

Readability formulas are included in some word processing software, and some web sites offer free readability calculators that allow you to cut and paste your text and have the reading grade level automatically calculated, he adds.

Diane C. Moyer, MS, RN, program director of patient education at The Ohio State University Medical Center in Columbus, prefers to use the Fry readability scale.

Using this method you select three 100-word sections in the document at the beginning, middle and end. You count the number of sentences in each section of 100 words and the number of syllables in each 100 words. You then find the average number of sentences and the average number of syllables. With this information and the use of a Fry graph, one can determine the reading level.

Moyer says a good resource for an overview of the readability tools is the book Teaching Patients with Low Literacy Skills by Doak, Doak, and Root, which is available as a free download at

To determine the reading level of materials used at Phoenix Children's Hospital, Fran London, MS, RN, health education specialist at The Emily Center, prefers the Suitability Assessment of Materials (SAM score). This too can be obtained from the book authored by Doak, Doak and Root in chapter four, "Assessing Suitability of Materials."

"I find readability formulas helpful in the initial writing of a document to help gauge the initial material. If you run your draft through a readability calculator and the results show a reading level of 11th grade or above, you know you have some rewriting to do," states Seubert.

The best way to use readability formulas is in training yourself to write in plain language, he adds.

While working on the manuscript, take a paragraph from the draft and calculate the reading level. If it is higher than desired, use plain language recommendations to rewrite the paragraph.

Tips on reducing reading level

To reduce the reading level of a written piece, look for complex sentences that can be broken into two sentences, replace words with multiple syllables with simpler alternatives, and change sentences in passive voice to active voice.

"Run the revised text through the readability calculator and notice the effect your changes have on the reading grade level. The more you do this as you write your documents, the more familiar you become with the plain language recommendations," says Seubert.

While writing, keep in mind the text should flow easily without sounding too choppy. There comes a point when cutting up sentences and paragraphs to get a lower reading grade level score does more harm than good. "Read your text out loud and notice how it flows," advises Seubert. "If it starts to sound too choppy, you've probably broken it down too far. The key is finding the balance so that your writing is clear, concise, and direct yet maintains a natural flow that is easy to read."

When doing a readability assessment of a printed handout, read through it and note any medical terms, as these terms can raise the score. Remove the term before running a reading grade level assessment, but do not remove a medical term unless it is clearly defined in the document, says Seubert.

Also, check lists of bullets. Typically, if bulleted or numbered text are complete sentences, they have a period at the end; if not, there is no period. To get a more accurate reading level, Seubert puts a period after each bulleted item whether it is a complete sentence or not, then simply removes the period after the assessment.

"If you don't have periods at the end of your bulleted text, the next period is most likely at the end of the first sentence that starts the paragraph following your list. That can result in one very long sentence with a lot of syllables and will make your readability assessment less accurate," explains Seubert.

He also advises adding periods after the title, headings and subheadings throughout the document. Putting the periods after headings and subheadings will separate them from the following sentence. Without them, the readability software will consider them as one sentence and that will affect the reading grade level score.


For more information on accurately using reading scales to score manuscripts, contact:

• Fran London, MS, RN, Health Education Specialist, The Emily Center, Phoenix Children's Hospital, 1919 East Thomas Road, Phoenix, AZ 85016-7710. Telephone: (602) 546-1408. E-mail:

• Diane Moyer, MS, RN, Program Director, Patient Education, The Ohio State University Medical Center, P.O. Box 183110, Columbus Ohio 43218. Telephone: 614-293-3191. E-mail:

• Doug Seubert, (NO DEGREES), Guideline Editor, Quality Improvement & Care Management, Family Health Center/Community Health Access, Marshfield Clinic, 1000 N. Oak Ave., Marshfield, WI 54449. Telephone: (715) 387-5096. E-mail: