How do Medical Records help Patients?

How do Medical Records help Patients?

1    IMAGINE YOURSELF
You visit your Dr or Nurse in your local health centre  but they don’t know who you are or your past history, what drugs you may be on or what treatment has or has not worked. You have been ill and need help.

You may have had malaria 3 times this year and reacted to one of the drugs and your partner has HIV/AIDS.

The consultations, in the clinic , are very quick as there are so many people waiting and you are only pleased to be seen by a qualified person.

The nurse gives you a written note for a prescription  without knowing past medical history  it may be that medication doesn’t work for you.

Get the Idea?

Effective medical care is impossible without chronological medical records and patient safety can be compromised without them

2    THINK AGAIN
You visit your local clinic again and they have a record of your name and past history on the screen. It is a different nurse but they can read you have had to return so have more time to ask you about the symptoms. There is a note from a previous discussion to say that you are to have a HIV test with any prolonged illness. The coding on screen shows us you have recurrent malaria and the nurse asks why this happens and do you have a malaria net to cover your bed?

The fact the test is on the computer means you go for a blood test and the blood taker doesn’t shout ‘what is she for?’ and the nurse shouts back ‘HIV test’.

The nurse arranges for the community health contact to help you get a malaria sleep net for you and your family.

The prescription given is clearly written on screen.

3    WHICH WOULD YOU PREFER? WHICH IS SAFER?

4    EXAMPLES
•    We now have easy to read records in date order clearly showing all past diagnoses and measurements, including weight, height, temperature, blood pressure and heart rate.
•    Before the computer, the weight recordings were for that day only and previous patient held data was frequently lost. Early intervention for malnutrition was therefore impossible.
•    Malnutrition can now be diagnosed by recording several readings over a period of time on the computer and alerting Health Care Workers to the problem. 
•    If we notice increase incidence of diarrhoea for example we can identify which villages have a high incidence and send Health Care Workers to areas of need. This enables best use of scarce resources.
•    Child aged 2 years attends and is unwell and looks pale and thin. Checking previous weights and upper arm circumference indicates gradual weight loss. Community nurse asked to see, and visit at home, to check on feeding regimen and circumstances of family and see child again to weigh.
•    All HIV patients have their follow up logged showing weight and drug compliance, allowing easier monitoring.
•    We forget much of what doctors and nurses tell us but with this system all patients can be interviewed after their visit to the clinic by a Health Care Worker who can look at the computer notes on her /his personal screen and make sure that the patient has understood the advice given and knows how to take their medication.
•    Peer Review….The clinic orders drugs monthly so as part of a clinical audit and a months consultations are reviewed to see who is prescribing what and if the prescription adheres to the agreed drug formulary. This prompts a lively meeting sensitively facilitated where evidenced based and cost effective prescribing is encouraged and behaviour changed………this will be repeated in 4 months time!
•    It has been shown in the Developed World for many years that the ability to measure disease prevalence and look at demography of diseases improves health care, saves money and most importantly SAVES LIVES. All countries deserve to have the same opportunity

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