ROJoson 2013 Medical Clinic Patient Registry Form – Revision 1

ROJoson 2013 Medical Clinic Patient Registry Form – Revision 1

NOTE: With the feedback from Marylou, I revised the form that I presented on December 5, 2012.

Each private medical clinic and each privately practicing physician have their own unique registry forms for new patients to fill.

The forms will vary depending on the needs of the clinics and the physicians.  As of this writing (December 5, 2012), in the Philippines, I am not aware of any Department of Health regulatory requirements on what should be the contents in such a patient registry form.

My personal registry form has evolved since I started private practice in 1981.  It started with an index card that just asked for patient’s data on name, age, sex, address, and contact number.  The cards were filed in index-card boxes.  Then, over the years, I cannot recall when, a one-pager form came into use that asked for more personal data together with data on diagnosis and treatment done that I had to fill at the lower part of the data sheet.  This form served as the covering page of the medical records of my patients in my clinic.

I have changed the contents of the one-pager patient registry form over the years.  As far as I can recall, I have changed them at least 10x already as of 2010.  I have records of  formal reviews of my form in 2006, then 2008, then 2010 (at 2-year intervals).

In 2010, I started asking for cellphone numbers and email addresses of my patients.

Today, December 5, 2012, I decided to review the contents again.  I am revising them to include among other things, Facebook addresses of my patients, if they have.

Below shows the new one-pager patient registry form that I will start using in January 2013.



As I said above, I still have records of reviews in 2006, 2008 and 2010.

Here are some excerpts from the records on the objectives of reviewing and refinement procedures to be done which I like to share with my patients and colleagues:

Objectives of Reviewing:

  1. To professionalize management of my clinic records (patient records).
  2. To use the improved management procedure of clinic records as a strategy in clinic development.
  3. To develop a model of management of clinic records to share to physicians-to-be.

Procedures in Records Creation and Generation:

Form should be filled by patient or relative and assisted by my secretary to ensure legibility and accuracy (secretary should not hesitate to fill another form if needed).

  • In the Patients’ General Data, include email addresses of patients and relatives – to use them for health advisory and  part of clinic development.
  • Include types of patients – insurance or not.
  • Include specimen signatures of patients and relatives – to facilitate signatures on informed consents and advice sheets.
  • Use the form to inform patients and relatives of my specialty – part of clinic development.
  • Include Patient’s Declaration of Health Information -to protect me if patients kept essential information from me that result to complications in management.
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