Medical Records in Family Practice

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Medical Records in Family Practice
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Introduction

• One of the most important tools used by family
  physicians in their practice are medical records
  and registers. They play essential roles in
  providing high quality health services in family
  practices.

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Important uses of medical records and registers
in family practice

• Providing data base for individuals and families.
• Help in providing continuity care.
• Help in vital statistics and decision making.
• Used as documents for legal aspects and
  investigations if needed (medico legal aspect of
  care).
• Help in auditing the health services.
• Help in communicating the relevant facts
  concerning the patients care among the health
  team.

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Criteria of good medical records

• They are organized in logical and systematic
  manner.
• They are complete.
• They are simple and accurate.
• They reflect the status of health and illness of
  the individuals and the communities.
• They could be retrieved quickly.

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Types of medical records and registers

• 1- Family Health Records (FHR)
• Family health records is a cumulative record
  (folder) of all family members. It gives data
  base about the family concerning
• Type of house
• Source of water, sanitation, lighting,
  ventilation.
• Number of rooms
• General health condition of the house
• It contains the individual medical file of each
  member of the family providing with all data
  base.

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2- Individual medical file

• Individual medical files consists of the
  following sheets
• Data base sheet contains
• - date of birth,
• - sex,
• - marital status,
• - educational status,
• - occupation,
• - medical,
• - surgical,
• - family,
• - social history,
• - drug history,
• - history of allergies).

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• b) Physical examination sheet includes initial
  clinical examination as
• - weight,
• - height,
• - BMI,
• - eye,
• - ear,
• - nervous system,
• - cardiovascular system,
• - respiratory system,
• - gastrointestinal system ,
• - musculo-skeletal system.

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• c) Lab sheet include base line investigations
  such as
• - urine,
• - stool,
• - blood and
• - electrolytes.
• d) Immunization sheet one sheet is provided to
  record the vaccines received by the individual
  child according to the date of administration/
  schedule.

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• e) Follow-up sheets they consist of many pages
  specified for follow-up visits. They contain
  space for
• - date,
• - vital signs,
• - complains,
• - clinical findings,
• - diagnosis,
• - treatment and
• - appointment.

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3- Problem (Patient) oriented medical record
(POMR)

• A) PAMR contains two main components
• - Data Base ( mentioned in the previous
  section)
• - Problem List The problem list is
• established after gathering of data base
• and conducting the relevant clinical
• examination and investigation.

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• Problem List could include
• Pathological diagnosis (Thyroditis)
• Disability (Deafness)
• Deformity (Scoliosis)
• Social (Poverty)
• Psychological (Stress)
• Clinical diagnosis (Hypertension)
• Chronic symptom (Fatigue)
• Active health problem (Bronchial Asthma)

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• B) Progress Note Progress note is designed to
  record the progress of the patient either for one
  or multiple problems in family practice. We
  usually use progress note depending on (SOAP
  system).
• SOAP system stands for
• Subjective
• Objective
• Assessment
• Plan

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For each problem, all these four elements should
be covered adequately.

• Example
• 45 years old male presented with cough for 3
  days. His chest examination revealed tachypnea
  and chest X showed left lung collapse . By using
  SOAP we can write the progress note of this
  patient as follows

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• Subjective What is the patient complaint?
• (Cough)
• Objective What is your clinical and lab
  findings? (tachypnea and left lung collapse)
• Assessment Severely distressed patient due to
  left lung collapse (diagnosis and clinical status
  of the case.
• Plan What should be done? Immediate referral to
  chest physician.

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• S Cough for 3 days
• O left lung collapse
• A Severe distress due to collapse of
• left lung
• P Immediate referral to chest
• physician

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4- Flow Sheets

• The flow sheets is a special sheet designed in
  relation to time. It is useful to find out the
  changes which occurred in a patient during short
  time. It has the following advantages
• Quick data retrieval
• Easy comparison of data
• Easy reminder to health professionals

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Flow sheet is usually to assess changes in
parameters such as

• Blood pressure in hypertensive patients.
• Blood sugar in diabetics
• Input/output of urine in patients with acute
  renal failure

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5- Special Lists

• In family practice we use some special lists
  which are considered advantageous for patient and
  physician. These lists could be used to remind
  the physician or can be used for auditing. These
  lists include
• Drug list (deals with the recording of all the
  drugs used by the patient ( name, dose,
  frequency, duration and route of administration).
• Health education list ( deals with the title of
  the topics which were discussed with patient such
  as diabetic , asthmatics and obese patients)

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6- Special forms

• In family practice we use special forms for
  special patient. These forms could be part of the
  patients file. Example
• Diabetic form which consists of many sheets
• - the first one designated for data base
• - the second page for follow-up visit
• - the third page for annual check-up
• - the fourth page for health education and
• - the fifth page for drug list
• Similar forms could be used for hypertensive,
  asthmatic and obese patients.

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7- Special Registers

• In family medicine and primary health care
  practice, we have many registers. These registers
  include
• Birth register
• Death register
• Drugs register
• Communicable disease register
• Morbidity register
• Immunization register
• Referral register

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Methods of medical records storage

• Medical records can be stored or retrieved by
  using many methods. However, the most common two
  methods are
• 1- Alphabetic filing system in this system the
  records are stored according to surnames of
  individuals. One of the common problems of this
  system is misfiling due to similarity of many
  names and ethnic group.
• 2- Numeric system this system is commonly used
  in Medical Record Department. This system is
  rapid and accurate
• .

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Electronic Health Records
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• Before the development of the Electronic Patient
  Record (EPR), the technology used recording
  information was in the form of logs or diaries
  and
• then the paper based patient record (PPR).
• The record tells the story of the patient's
  journey through the healthcare system.
• As a result the patient's record has now become
  an even more vital component in the provision of
  care.

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• Throughout the literature various terms are
  used to refer to automated health information
  systems
• Electronic Patient record (EPR)
• Electronic Medical Record (EMR)
• Electronic Health record (EHR)

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• While these terms might be used interchangeably,
  there are slight differences between each system.
• The common characteristics among them are they
  are all used to collect, store and manage patient
  information.

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• EPRs and EMRs contain patient information
  gathered and accessed from a single site, or
  information transferred from another site.
• EHRs contain longitudinal personal health data
  across the continuum of care.
• A network of EPRs and EMRs and other data stored
  through other clinical technology forms the HER.

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• Family practices (the first point of contact for
  many patients) are one of the most common
  settings for using EPRs.
• In one country there should be one system
  implemented because with the implementation of
  different software there is complexity , such as
  the development of interfaces between the
  different software to enable the exchange of
  information.

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• As one of the key objectives of primary health
  care network is the integration of the continuum
  of services and information technology is viewed
  as one of the enablers for this integration.
  
  

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• An electronic health record (EMR) is a health
  record in digital format.
• Electronic Health Record Is a most important tool
  for management of health care information in
  Health care Organizations, which provides online
  information in Health care facilities by using
  computer capabilities.

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• The electronic health record is a longitudinal
  collection of patient-centric, healthcare
  information, available across providers, and care
  settings.
• It is a central component of an integrated health
  information system.
• Electronic health records have the potential to
  save hundreds of hours of time, reduce cost of
  care, while improving patient care.

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What is Interoperability?

• In healthcare, interoperability is the
  ability of different information technology
  systems and software applications
• to communicate,
• to exchange data accurately, effectively, and
• consistently, and
• to use the information that has been exchanged.

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Many benefits have been listed for the
utilization of electronic records

• 1-instant and universal access to the patient
  record
•  
• 2- easier and quicker navigation through the
  patient record
•  
• 3- standardization of care among providers within
  the organization
•  
• 4- clinical data that is formatted to be easy to
  read and analyze
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• 5- reduction of paperwork, documentation, errors
  of filing activities
•  
• 6- alerts for medication errors, drug
  interactions ,patient allergies
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• 7- ability to electronically transmit
  information to other providers (assessments,
  history, treatments ordered, prescriptions, etc.)
•  
• 8- availability of clinical data for use in
  emergency

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• Applications

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Medication Prescription

•   A provider need only enter the information for
  a new prescription in the EMR, and that
  information is put on the patient's medication
  list.
• The computer keeps track of when the prescription
  was written, the amount ordered (and later
  dispensed by the pharmacy), and the number of
  refills.

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• This capability saves time and improves
  communication with the patient, the pharmacist,
  and subsequent care providers.

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 Medication Reconciliation

• Managing multiple medications has increased the
  complexity of everyday patient care, especially
  care of the elderly.
• The computer automatically checks for allergies
  and drug-drug interactions whenever a new drug is
  entered.
• Although not all of the drug interaction alerts
  generated by the computer are clinically
  significant, the physician is prompted to
  consider the severity of the conflict and act
  accordingly.

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• If the physician is not knowledgeable about the
  type or cause of the interaction, a full
  explanation is available at the touch of a screen
  or with a single keystroke.
• Pharmacy computers can keep track of
  prescription refills and alert the physician if
  the patient appears not to be taking a medication
  regularly. Other physicians can access the
  patient's medication profile in the EMR before
  prescribing a new drug.

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Laboratory Test Results

• Ordering laboratory tests and reviewing the
  results on a timely basis is an important
  component of patient care.
• When laboratory tests are ordered electronically,
  the information is entered into a log, so that
  tracking the return and review of results is
  reliable and efficient.
• For laboratory work that is performed in the
  office, such as blood tests, electrocardiograms,
  or radiographs, the computer automatically
  captures the proper information for billing
  purposes.

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• When results are returned to the physician, they
  are reviewed, and the patient can be notified of
  normal results or of the need for further
  testing.
• An electronic method of tracking and obtaining
  results reduces delays in patient care provision
  and eliminates periods of concern for both
  patient and physician.

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4-Record of Office Visit

• An accurate record of the office visit is
  essential to the provision of good patient care.
  Various members of the clinical team enter
  information using templates.
• The nurse or medical assistant may enter a
  portion of the note, such as
• - the reason for the current visit,
• - any concerns expressed by the patient,
• - vital signs, and
• - a review of current medications.
•  

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• Physicians usually enter information about the
  patient's history and physical findings, along
  with diagnostic impressions or conclusions.
• The traditional written narrative in the office
  visit note may easily obscure both normal and
  abnormal findings by embedding them in the middle
  of a paragraph or page, requiring the reader to
  scan the entire page to find the one piece of
  information the reader is looking for.
• It would be far more efficient if normal and
  abnormal items were highlighted in some way for
  easy recognition.

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• Structured data entry allows information to be
  entered into the computer in a way that is easy
  to search and retrieve. Pick-lists allow
  clinicians to choose from standard complaints,
  history items, and physical findings in the
  course of constructing the final note.
• There is also the option of displaying the note
  either in tabular form or in narrative form. With
  structured data entry, the necessary elements for
  coding and billing can be determined more
  readily.
• A plan of action or follow-up recommendations
  complete the office visit note.

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Office Workflow

• One of the greatest benefits of the EMR is
• to facilitate office workflow.
• Intra-office messaging,
• responding to patient phone calls or e-mail
  messages, and
• providing medication refills are all part of the
  daily office workload.

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• Even though the average family physician may see
  25 to 30 patients face-to-face in the office each
  day, an additional 75 to 100 interact with the
  office through some other means-phone, fax, or
  e-mail.

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• They may call for advice about
• minor problems,
• prescription refills, or
• referrals to other providers.
• In a paper-only system, each of these 100
  interactions requires a special clerk to
  manually do all this work.

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• The EMR allows any member of the care team to
  access the medical record at any time, regardless
  of location. Most systems allow multiple users to
  access the same patient's chart at the same time.
  

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• This capability is essential for efficient time
  management and to reduce waiting times and
  delays. The ability to access patient records
  from remote sites is especially important for
  physicain groups with multiple practice sites and
  for physicians who are on call while at home or
  at the hospital.

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STANDARDS

• Most office-based health information technology
  in use today, including the EMR, cannot be used
  to exchange much information with laboratories,
  pharmacies, or patients and family members.
  Connectivity between the practice EMR and these
  important sources of information within and
  outside the office practice environment is
  necessary to prevent computerized systems from
  becoming data islands.
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• A growing number of data content, format,
  vocabulary, and messaging standards play an
  important role in health IT adoption. Perhaps the
  most significant to family physicians is the new
  interoperability standard called the Continuity
  of Care Record (CCR).

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• The CCR is not an electronic health record but
  rather a snapshot of the information the medical
  record contains at a given point in time. The CCR
  is compatible with other efforts to standardize
  health information systems and can work in
  conjunction with these efforts.

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• The CCR is a document standard for basic
  health information that uses XML (extensible
  markup language). The CCR is intended
• to foster continuity of patient care,
• to reduce medical errors,
• and to increase patients' role in managing their
  own health care.
• It will also enable epidemic monitoring, public
  health research,
• and ensure at least a minimum standard of secure
  health information transportability.

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• Utilizing Technology in health care facilities is
  no longer the future.

IT is TODAY!!!