Need to know basis…

For Your Eyes

The “One Patient, One Record” plan has been much ballyhooed by both our provincial medical society and the NB Department of Health.   Don’t get me wrong, I think the concept of having a single accessible medical record for every person in the province is a great idea.   But there should be some constraints on who is able to see what, and respect for patient privacy deserves top priority.

It seems to me that if a primary care practitioner is seeing a patient for the first time, it would be EXTREMELY helpful to have access to that patient’s recorded medical history.   Paper charts are OK, but they tend to be disorganized, have “legibility issues” (euphemistically speaking), and are a usually miles away, locked in a closed office when you really need them.

Electronic records seem to be the perfect solution.

The other question is this: if you are assessing a patient in an after hours clinic, do you really need to know EVERYTHING about their medical history?   Keep in mind there will be many things in that chart that may have been told in confidence to a trusted family physician, who the patient has known for years, and with the expectation that nobody else will be reviewing the office notes.   Just to name a few sensitive issues that may be in the chart: 1) requests for STD testing from a patient who suspects their spouse of marital infidelity, 2) discussions of workplace conflicts, 3) remote substance misuse history, 4) personal beliefs and religious views.

Now there could be some situations where information like that may be required.   That’s why we take a history from the patient.   Most of the time, most of the stuff you find in a complete chart is dross, and not relevant to the current issue.   So why make it available?

I think the solution is to have a limited “One Patient, One Record” system which provides the key points of a patient’s health history in one or two pages.

Here is a sample of what that would look like, taken from my EMR.

Image

What do you think?

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One thought on “Need to know basis…

  1. Fine idea. Non-FD treating doctors, eg after hours clinic, ER, needn’t know gramps molested so-and-so, or patient x had 3 suicide attempts when he just needs biaxin. In paper terms this is the CPP at the front of the chart. Good idea, one even I could adopt as a first step in emr, while still charting the details on paper charts, which I jealously maintain for my own smooth daily operation and personal sanity. I don’t like typing ( even now as I do this) because I suck at it and don’t care to spend time learning. Pen from my cold dead hand and all that…another topic.

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