Patient Record Keeping: are you meeting the new legal requirements?

March 6, 2013 - PRLog -- No matter what kind of medical or health care discipline you practice in, you are, or shortly will be, required to take a full case history of each and every patient you see. In 2012, the current Australian Government introduced legislation that required physicians of Chinese Medicine to become registered. Subsequently, the newly formed Board of Traditional Chinese Medicine has issued update after update with proposed minimum levels of Medical History taking.

While most orthodox medical practitioners rely heavily on laboratory testing and digital imaging, we as non-orthodox practitioners have very limited access to such tests. However, we do have a very comprehensive system of diagnosis. Most disciplines be it Chinese medicine, Ayurvedic medicine, Herbal medicine, Naturopathic medicine, etc., all have a sophisticated system of diagnosis that has evolved over millennia. Remedial body therapists, Psychologists, Chiropractors, etc. all rely on their ability to take a complete record of their patient’s presenting health concerns and their medical history in order to prescribe an appropriate course of treatment.

Unfortunately, with increased time pressure on health care professionals, often times patient records are not as comprehensive as they should be, and in some cases, patient records are totally incomplete and insufficient.

I remember as a student of Traditional Chinese Medicine (TCM) taking two hours and sometimes more to take a full history when first starting out seeing patients in the student clinic. We looked at their pulse, tongue, skin, eye-colour, hair, nails, muscle tone, and so on and asked the patient what seemed like a million questions. We did a physical examination, palpating the Liver, Spleen, abdomen, looking at their posture, etc. However, after many years of being in practice, on occasions it only takes a few specific questions, careful listening, brief observation and you know what the patient in front of you suffers from.

This is where we can run into potential problems. By skimping on taking a full history, not including taking their blood pressure, or pulse or even looking at their tongue, or whatever, we are potentially missing a serious underlying health problem. We may even make an observation, but neglect to write it down. The point is that we are now a registered health care profession and with this ‘status’ come certain legal responsibilities.

These days, many patients look to us as their primary physicians and no longer consult their GP (or MD in the US) in the first instance. Many people are increasingly frustrated with their doctors because when they present to them with an illness, they get given a script, which either does little for them or makes them feel even worse (obviously, this does not apply in all cases). Fed up with this approach they seek more holistic help and come to see us instead.

This places a great deal of responsibility upon us as physicians, because now, the patient in front of us has not been screened by laboratory tests, imaging or their doctors’ questions. Instead we have to make sure that their illness in not a life-threatening one and rule out any of the ‘nasty’ diseases they may be presenting with.

This is where taking a full case history is of primary importance and will help you to explain why you took the course of treatment you embarked on, should things go wrong. If your history is incomplete, you may be in serious trouble just because of that.

The Challenge to Physicians
We are all human and therefore imperfect. We make mistakes, we have bad days, we may be tired or upset, we’re under time pressure, etc., etc. Despite this we have to push through these days and give 100% to each and every patient that walks into our practice that day. This is when the risk of making a big mistake is at it’s highest.

I remember late one afternoon after a very busy day a patient came to see me with acute low back pain. He had been working 12 hours straught, loading trucks the day before and woke up with a sore back – no surprise there.

I asked him the standard questions to rule out acute sciatica, performed a couple of tests to rule out a herniated disc and other possible back/kidney-related health issues, but no obvious symptoms where to be found. I had made up my mind to treat him for a simple low back pain due to overworking, but at the last moment, decided to take his blood pressure. To be honest, there seemed no reason whatsoever to do so, but I did. His blood pressure was 220/110. This now became a medical emergency rather than a simple low back pain...

The Solution
It is stating the obvious, but at the very core of our treatments lays a thorough history. If it is incomplete or lacking detail, there is a good chance the diagnosis and thus the selected treatment will not achieve the desired result. This is where an electronic patient record management solution can be of great help, because it is designed to take the user through the full range of diagnostics. Doing this is simple, efficient and most important of all, thorough.

This is one reason PRMS has been developed. It has taken over 20 years to reach its current level of sophistication, yet it is so simple you can start to use it straight out of the box.

All the information about your patient is on one single page in front of you. No longer do you have to shuffle through notes on paper in a file, it’s all right there, irrespective of how many times the patient has been to see you.

All the fields you should use to ensure a thorough set of diagnostic information are on one single page. There is virtually an unlimited amount of information you can enter, ranging from photos, videos, scanned copies of MRIs, X-rays, Ultra-sounds,  to PDFs or a combination of all of these.

In addition, it also allows you to instantly complete and print out invoices/receipts as well as complete and print your treatment program, which you can then hand to your patient.

Further, legislation in Australia now requires that your herbal prescription list each of the herbs you have used in your preparation and that this is given to your patient. PRMS allows you to do just that and more.

Conclusion
In today's world where ‘alternative’ medical practitioners are facing increasing responsibility and legal requirements it is becoming increasingly important to safeguard our patients and ourselves by keeping medical histories that stand up to scrutiny and comply with all the requirements that are placed upon us. For this reason alone it is paramount that we invest in tools to help us achieve this and provide us with a standardised mechanism to thorough history taking.
 
I encourage the reader to take a close look at this patient record management solution (please visit: http://www.PatientRecordManagementSolution.com.au); it just might take your case histories and patient record management to a whole new level.