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THE PATIENT RECORD

A health record is a compilation of pertinent facts of an individual's health history, including all past and present medical conditions, illnesses and treatments, with emphasis on the specific events affecting the patient during the current episode of care. The information documented in the health record is created by all healthcare professionals providing the care.

Evolution is a constant phenomenon just like change in common parlance is said to be constant. The patient record has passed through different phases over the years. This changes can be said to have been influenced by the increasing need of accurate and substantial data from clients, proper documentation, the medicolegal/ ethical issues, increasing complexities and knowledge of closely related diseases and associated co-founding factors, and also the need of the same information among specialists (multidisciplinary approach ) and other workers in the health sector e.g hospital administration.

The patient records system dates back to Hippocrates. He started by making notes of the details that preceded the patient’s illness only and the events follow in chronological order. This type of record is called time-oriented medical record, and was novel in the fifth century B.C. This record system is at best casual though it was designed to tell the course and prognosis of the disease.

Subsequently the physicians were made to follow a set of guidelines in taking the notes as the relevance increased and also the need for some standardization. Weeds introduced the SOAP structure.

SOAP; S- subjective, O- objective, A- assessment and P-plan

Subjective details in the notes include details from the patient and this includes the patients’ history and physical examination.

Objective details include data from laboratory investigations and biological signals like electroencephalogram, electrocardiography and spirometry.

Assessment is what the physician’s diagnosis based on the patient’s history and physical examination or the present state of the patient assuming this patient has been in the physician’s service for a while, or simply put the conclusion.

Plan is the treatment modality outlined in managing the patient short- or long term.

Weed’s SOAP structure ushered in the problem-oriented. It was generally accepted because it reveals the thought process of the physician (for care), and standardization of the record system.

Today, modern patient records are not purely in chronological ordering. The wide range of investigative procedures is at best kept away from the visit notes of patients and the nurses’ notes to facilitate trend analysis. The modern patient records are electronic based and are source oriented. The paper based record system cannot fulfill such effectively. Should it, then you need more workers who will substitute the electronic medium in the transfer of data across departments. This will be expensive and will defeat its merit.

Functions of the Health Records

• It supports record keeping. • It is an employment and training opportunity • It supports patient care. And the data recorded can be shared among the clinicians/ care providers. • Data can be used for a wide spectrum of research studies: epidemiological studies, quality of care assessment, and clinical audit. • It provides support for hospital management in aspects of billing and reimbursement, healthcare financing, budgeting et cetera.

PAPER –BASED PATIENT RECORDS Most of the clinical and administrative information that flows throughout the health care system is still recorded on paper. Over 10 billion pages of patient records are produced in the United States each year, each of them a masterpiece of idiosyncratic functionality. In order to receive accreditation, hospitals must ensure that their records meet certain minimum content standards established by the Joint Commission on Accreditation of Healthcare Organizations, as well as any content requirements mandated by state regulations. In general, however, health care organizations are free to determine how the information is arranged. Institutions design their own filing and communications systems to meet internally determined information needs, and individual departments often design forms to reflect information generated in self-contained processes. To some extent, paper records are individualistic even to the level of single sentences because much of the information is handwritten and clinicians may phrase entries using their own terms and conventions. Paper records contain different types of information. Different types of providers might assemble records with different content; for example, ambulatory care records generally have fewer categories of information than hospital records, but they may span a much greater time period because they are historical records documenting many encounters. Patient records also incorporate administrative records such as letters, insurance claims, and bills, although these may be stored separately from clinical records. Paper records within a single folder have traditionally been kept either in the chronological order of collection or in source-oriented or problem-oriented formats. Source-oriented records are organized with forms from nurses, physicians, labs, and other sources in separate sections. Problem-oriented records organize the various notes into a brief database of information identifying the patient, a problem list of the aspects of the patient’s condition that require treatment, an initial plan for treating the problems, and progress notes detailing actions engendered by the problems and plans. This lack of standardization of patient records is not necessarily a symptom of poor design; instead, it is a reflection of the main task that patient records once served. They were a highly detailed, patient-centered documentation of the care process and a record of everything that happened with respect to a patient during a particular episode of care. In ambulatory care settings, they were also repositories of historical information about an individual’s previous care. The records mediated communications and conveyed instructions and responsibilities among members of the medical team. In this context, designing a standard format for documenting patient-clinician encounters made about as much sense as trying to enforce a standard format for phone conversations or diary entries. The problem is that the functionality required of patient records has grown far beyond the bounds of record keeping and communication within a limited team because of changes to both the delivery system and clinical practice. Patient records are now widely used for legal, administrative, and research purposes. They have become sources of information for determining eligibility for insurance payments and for documenting the extent of injuries or the quality of care for use in legal proceedings. They may be used to provide data for evaluating the quality and appropriateness of care for peer review, accreditation, or other quality assurance programs and for reporting communicable diseases and other required data to civil authorities. With the advent of integrated managed care organizations, clinical records have become information sources for analyzing the resource requirements, outcomes, and profitability of health care practices. In response to these broader functions, patient records now have at least two phases. In the active phase, clinicians and administrators insert and edit information. As legal documents, patient records are treated like other business records that might be needed in a trial. Recorded entries must be made by people with first-hand knowledge of the events, acting in their ordinary capacity, and the time and date of each entry must be shown. When errors are found and corrected, the record must show clearly both the original entry and the correction, along with the name of the person making the correction. Tomes points out that in the passive, permanent phase the patient record serves as an unalterable legal record. Its contents are occasionally examined, usually by users far removed from the clinical setting. At this point, information may be abstracted from the record for research or management purposes, and all links identifying the information with a particular individual removed. Even with this adaptation, paper records may not be adequate for the information demands of modern health care delivery systems. Given below are the weaknesses of paper records: • Paper-based patient records document the care giving process inadequately. Medical record keeping is a hurried, ancillary activity in the encounter room. Clinicians may not have enough time to completely and accurately fill out the forms comprising the paper records, and the required health information is sometimes unavailable or of questionable accuracy as the notes are written. Physicians’ and nurses’ notes may be illegible if handwritten, or inaccurate if dictated and then transcribed. Detailed descriptions of the patient’s health problem and the reasoning behind diagnoses and choices of services may be left out or abbreviated because they are hard to summarize and tedious to record. The voluminous data from physiological monitors are difficult to record accurately by hand. Other components, such as laboratory and radiological reports, may be missing because of filing or communication errors.

• Paper-based patient records hinder information flow. Once information has been recorded within a set of bulky paper records, it may not be readily accessible later. Efforts to compile a more complete paper record are likely to exacerbate this problem. The data are bound to the paper itself and individual pieces cannot be sorted for relevance, making the record difficult to use when dealing with multiple problems or extended treatments. Collecting and aggregating data from multiple records for purposes of quality monitoring or clinical research involves an expensive and time-consuming manual search. Paper records can be in only one place at a time. Short of laboriously photocopying and then shipping them by courier, records may frequently be unavailable to a caregiver who needs them. When the record is unavailable, new data cannot be entered in a timely manner; entries must often be made from memory or copied from other forms or informal notes. This can lead to the creation of "shadow records" that are difficult to coordinate with the primary record set and which may contain conflicting or anachronistic data. Finally, the data are only as secure as the paper itself, and entire records, or individual pages within a record, can easily be misplaced, damaged, lost, or stolen.

• Paper records impede the integration of health care delivery, research, and administration. The wide variety of formats, styles, and organizational systems for paper records frustrates the coordination of care between different providers, or even between departments or practitioners in the same institution. The impenetrability of the record means that there are few tools that can use information in the paper records to generate reminders, decision aids, and other supports for work.

WHY ELECTRONIC RECORDS?

The electronic health record (EHR) is a computer-based electronic file that resides in a system specifically designed to support users by providing accessibility to complete and accurate health data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids.

Population rise, the continuous need to satisfy the needs of clients and consulting physicians, and particularly the pacing growth of medical knowledge which led to specialization and the corresponding need for multidisciplinary care pushes the need for electronic patient records in most parts of the world.

Given hypothetical patients, a physical (paper) record is many times too little. Many patients need to see more than a specialist in the course of hospital stay/ consultation. Paper files can only be at a place at a given time, and sometimes they are missing as a result of frequent interspecialty movement or associated logistics.

Paper as a medium of transfer of information is fraught with many disadvantages.

The record can be only be at one place at a time. The records are in free text and are likely to face problems of illegibility and ambiguity. It is also prone to destruction by rats, rodents, and insects.

Differences between Paper Based and Computer Based Patient Records

1. A paper based record is static; a computer based record is dynamic. 2. A paper based record can be presented only at a place unlike the computer-based record which can be assessed at different locations. 3. Paper based records can not be easily reproduced while CPR can be easily reproduced in form and back up. 4. PBR has a fixed ordering of the data; computers can retrieve data in different sorting orders

Electronic Health Records The electronic health records (EHR) contains both documents in an electronic form and functions including: patient demographics; medical history, examination and progress reports of health and illnesses; medicine and allergy lists, and immunization status; scheduling, retrieval and archiving of laboratory and other tests; graphic image display of X-rays, MRIs and other medical imaging studies; medication ordering, including patient safety functions to minimize interactions or side-effects. Others include: evidence-based recommendations for specific medical conditions, termed clinical practice guidelines; appointment scheduling; claims and payment processing; patient reminders of follow up appointments, test completion, preventative health practices. Medical reporting dates back to Hippocrates – fifth century B C.

Advantages of Paper Based Records

• There is freedom in the style of reporting • Data browsing is easier • Little or no training is required. • They can be easily carried about. Individual patient records are handy. • Access to records is independent of electrical power. This is a greater challenge for people in low resource settings.

Advantages of Electronic Health Records

• Data is presented legibly • Variety of view of data is possible • It can support other data analysis. • Simultaneous access is possible from multiple locations • Decision support system is compatible • Data exchange is easier

Other Uses of the CPR

Non-medical establishments, insurance companies and hospital services/management need patient data. Their request is driven by needs such as assessment of quality of health care delivery, billing. A CPR is almost sine qua non in achieving efficient delivery of data. But wide acceptability of this system will come by effective change management.

Paper Record Problems versus Electronic Record Solutions

Coordination The average patient today has 11.2 different medical records in existence. These numerous records are difficult to coordinate, and often are not shared between different providers treating a patient. Even when they are, providers with different specialties may not be able to easily interpret one another’s notations. The electronic health record helps integrate clinical viewpoints and facilitates shared care by using a reference terminology. It recognizes the different forms of expression used by the various clinical specialists for identical concepts.

Organization Every provider has a different method of recording information, and what seems clear to one may be haphazard to another. Critical data may be unavailable when needed – lost in the clutter, on the wrong chart, in the wrong section of a chart, or not charted at all. The electronic health record provides a standard method for recording patient information that is easily accessible and retrievable. It brings a new level of quality and connectivity to the record.

Proliferation The number of forms used to record and control health care continues to increase by leaps and bounds: in fact, one study examining nursing forms found 386 forms in simultaneous use in one small hospital. The electronic health record drastically reduces paperwork by aggregating the majority of information currently contained in paper forms into one electronic source. With ER solutions, data can be captured once and reused endlessly for documentation, decision support and statistical reporting.

Patient Input With numerous paper forms, a patient’s record is not easily portable and does not automatically follow when the patient moves or changes providers. As a result, patients must repeat the same information over and over again and may inadvertently leave out vital information. Patients provide information once and it can be made available throughout their lifetime to any provider of their choice. When information is computer coded, any provider of care can immediately apply and understand the information – even if using a completely different language.

Co-Location Paper records can only be at one place at one time, meaning that providers at different locations cannot easily access and review a patient’s records and medical history. The electronic health record can be accessed and viewed by providers who work across the street from one another, across the country or even across the world, ensuring that the most up-do-date information is always available at the point of care.

Linkage In paper records, there is no automatic means of linking or retrieving practice enhancers such as clinical alerts, health education tools, medical literature and knowledge databases. The electronic health record can link clinical documentation to e-coded literature references, education materials, treatment guidelines and other practice enhancers.

Data Aggregation For population-based studies and outcomes, abstracting medical records adds unnecessary administrative costs to the health care system. With well-coded electronic health records, the promise of administrative simplification and evidence-based medicine on a global scale can be realized.

The Next Stage

In recent years, it has been demonstrated that for CPR to be more complete, images and signals need to be added. The word Multimedia Patient Records was coined to describe this. It will require the development and installation of one integrates solution or the upgrading of systems by adding new software and introducing the new technology. Also expertise in networking, communication and integration is required.