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Thread: Record Keeping

  1. #1
    Join Date
    Mar 2016
    Posts
    271

    Record Keeping

    I'm trying to come up with a basic form for keeping medical records, should the need arise.

    Seeking input from you all-
    Was thinking a simple 2 page form, with front & back. First 1/4 page dedicated to "signalment": DOB/age, sex, weight, presenting complaint, TPR (temp, pulse, resp), etc. Remaining page for SOAP / notes space. Also going to print some generic pages with lines for continued records.

    Does this sound logical? What things would you want to see on a medical records page?

    No suggestion is too simple or silly here. I'm trying to improve on "54# spayed female black/tan lab mix dog"... so all recommendations are appreciated!

    -AnimalDoc

  2. #2
    Join Date
    May 2001
    Location
    Iowa, USA
    Posts
    5,158
    It is going to depend on what you have for capabilities. If you can run labs of any manner - even a simple glucometer reading or urine dip sticks - you'll want space for them. Perhaps another sheet for those.

    I'd consider something simple like a pocket folder like this: https://www.amazon.com/Lion-2-Pocket.../dp/B00FFJWSCE

    A very expensive example I grant you but you get the idea. Considering that the clinic you envision wouldn't be generating social service reports, CT scans, daily multi-page labs, various assessments and legal notification documents and all the other drivel that comes with a regular hospital or clinic you could have a chart covering a 2-week 'hospitalization' in a folder like that. Easily.

    Here are some examples of simple charting, i.e. Progress Notes: http://ratelco.com/bnVyc2VzLW5vdGVzL...nLWV4YW1wbGVz/

    In a grid-down world 95% of what goes in a hospital chart is worthless drivel. The other 5% should consist of your 'signalment' section, a medication reconciliation section, a decent PMH (Previous Medical History) section, and then ongoing Treatment and Progress Notes.

    Hopefully AN can chime in with what manner of records were kept overseas for NGO missions.

    RR
    Knowledge shared is learning gained by both teacher and student.

  3. #3
    Join Date
    Jan 2008
    Location
    oregon
    Posts
    664
    In he past when working as Doc for large groups in remote areas without internet connectivity I have used simple soap notes on a modified SF600 form. I pre copy a place for a front and back oblique human with dermatomes VS and labs on the form. otherwise its just lined paper with a name SSN unit and DOB block. Just write date time and a SOAP note.
    This is stored in a expandable, tabbed alphabetically, briefcase from Staples.
    Each person has a basic medical Hx, allergies, meds (SAMPLE) and eyeglass Rx on a simple form.
    Logistics piggybacks on my file with shoe sizes and clothing sizes.
    This way I have a start when seeing patients and I add to each persons paperclip file sorted by name.
    The whole thing with basic office supplies goes into a locked pelican case with a bike cable and lock to keep it safe. There is a small cheap camera in there for taking pictures that are sorted numerically and the number placed on the SF600 so I can evaluate wounds rashes infections etc over time. When online I can send images for a consult out of the area.


    There is a never online laptop with medical reference in there as well in a metalized cloth pouch to limit unauthorized access and a separate issued laptop for secure online access. The 2 computers never talk to each other. The first one has no patient data on it. The second one can access a offsite database and medical record when secure internet is available.

    pa4ortho

  4. #4
    Join Date
    Jul 2007
    Posts
    514
    Kind of a side discussion.

    Medical records serve a few purposes:

    1) To remind you what you did for the patient when they return for a visit.
    2) To pass information along to another clinician so they know what you have done and what you are thinking (with on referral or return visit).
    3) Medico-legal.
    4) Research.

    I think that most records (in the US) serve the third point which is not really important in a RAWTHW situation. Heck, would life be nice if you did not need to chart with the constant thought of, "if a lawyer reads this in court, what will they think is going on / I did?). Statements in the notes like, "After obtaining consent, I proceeded to prepare the limb using standard aseptic practices" is not helpful to anyone.

    I would caution you on medical record keeping depending where you work. Medical records can be very dangerous and I have has a number of time where people have shown up (often armed) and demanded to see who I was treating a my austere medical clinic and what I was treating them for. Often because they wanted to know what happened to someone (sexual assault), were looking for someone and/or wanted to pin my allegiance to one side of the conflict or another to my organization... this in an environment where my conflict neutrality was part of my survival methodology). If you do not need the medical records do not keep them. When I worked in Sri Lanka I used to give the patient my notes and have them bring them back to me on repeat visits so that the Tamil Tigers could not gain information from my clinic.

    SOAP note is as good as any. I often use the following:

    Date:
    ID: (Name, Age, Sex, Occupation)
    Chief Complaint:
    Past Medical History:
    Allergies:
    Medications currently taking:
    History of present illness:
    On examination:
    Labs:
    Imaging:
    Diagnosis or differential diagnoses if I do not know what is wrong yet.
    Treatment (Plan):
    Follow Up Plan:

    For example:

    Date: 2 Mar 18 @ 1730 hrs.
    ID: John Smith, 34 Y.O. Male Farmer.
    C/O: Pain in Right Ear.
    PMHx: Otherwise healthy. No previous problems with ears or throat.
    Allergies: NKDA.
    Meds: Tylenol, 500 mg last dose 1530 hrs. No other meds.
    HPI: Otalgia right ear only - started mild now severe, progressing over 3 days, mild hearing loss, ear fullness. No tinnitus, fever, itching. Discharge started clear and odorless but has turned purulent and foul-smelling. As been swimming in the river, four times a week for the past month. No hx of ear trauma.
    O/E: Temp: 98.5F, pulse 90 and normal, pain localized to right ear, no deep structures involved, stabbing, no radiation. Increase pain on traction to the pinna, 7/10, worse on head movement, less on bed rest with ear up. No trauma. Notable purulent and foul-smelling discharge. Visual - erythema, edema, and narrowing of the external auditory canal. Could not visualize tympanic membrane. No granulation. Left ear normal. Some conductive hearing loss. No cellulitis of the face or neck or lymphadenopathy found. CN VII / IX-XII normal.
    Labs: None.
    XR: None.
    Dx: Acute Otitis Externa, possible perforated TM.
    Tx: External auditory canal cleansed. 2% Acetic acid otic solution, 4 gtts QID with wick x 3/7. No swimming. Tylenol PRN.
    F/U Return to clinic in 3 days for re-exam.

    If you read this note and re-examined the patient you would know what I thought was wrong and if his condition was getting better or worse.

    I hope it is useful.

    AN

  5. #5
    Join Date
    Mar 2016
    Posts
    271
    All,

    Very helpful - thanks for your input.

    I appreciate the comments on no records, AN. Large part of recordkeeping for me would be self-reflection and learning from past experiences. That could be accomplished, though, by a simple medical journal with no names included.

    -AD

  6. #6
    Join Date
    Sep 2001
    Location
    Down under
    Posts
    567
    I just use a hard cover A4 note book and just write using an an abridged standard medical history - number the pages and link back if she the patient multiple times.
    I have an accumulation from over the years - fun to look back on !!

    cheers
    Craig

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