Importance of Keeping Medical Records – An Illustration

Here is a vivid illustration of the importance of patients keeping their medical records and bringing them to the physicians for check-up / follow-up.

In the past, I have been given advisories on the importance of patients keeping medical records.  Below are some links to my advisories.

Links:

https://rojosonmedicalclinic.wordpress.com/category/keeping-medical-records/

http://rojosonfacebooknotes.wordpress.com/category/keeping-medical-records/

One of the reasons I have given before for patients to keep their medical records is that their records may be lost in the doctor’s clinic or they may be discarded already.  Keeping and bringing medical records will mitigate the problem of lost and discarded records in the doctor’s clinic.   

Here is a full documentation of an event (February 2014) that illustrates the importance of  patients keeping and bringing medical records with them when they consult  with or have a follow-up / check-up with a physician.

February 2014, a 50-year-0ld female patient from Camarines Sur came for follow-up / check-up for her breast concern.  Her first consult with me was in 2007 and then another consult in 2010 and most recently, in February 2014.

For one reason or another, my secretary could not locate the clinic records of this patient during her most recent check-up / follow-up with me.

Fortunately, the patient brought along all her past medical records and the duplicate notes that I gave her in 2007 and 2010.  This greatly facilitated the medical consultation.

I have the practice (and habit) to give all my patients a duplicate or carbon copy of my notes and explanation. I am still trying to trace when I started doing this, probably circa 2000.

I also usually ask my patients to always bring their past medical records whenever they come for check-up or follow-up with me.

What occurred in this patient last February 2014 made me feel good and delighted.  I congratulated the patient for a task well done.  I also decided to document the event so that I can use this to reinforce my advisory on the importance of keeping and bringing their medical records to the physician during their check-up / follow-up.

Slide6

Patient DB from Camarines Sur bringing her past medical records when she consulted me in February 2014.

Slide4

Her past medical records that contained the 2007 and 2010 notes and explanations that I gave her.

Slide1

The 2007 notes and explanation that I gave her. Note the signature of the patient (purposedly partially covered by me) that I usually ask my patients to affix as part of the process of informed decision-making (informed consent /refusal).

Slide2

The 2010 notes and explanation that I gave her. Note the signature of the patient (purposedly partially covered by me) that I usually ask my patients to affix as part of the process of informed decision-making (informed consent /refusal).

Slide3 The 2007 and 2010 notes and explanation that I gave her.

Slide5

The 2014 notes and explanation that I gave her.

Slide7The 2007, 2010, and 2014 notes and explanation that I gave her which are now part of her own medical records files.

ROJ@65@14mar2

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In the near future, I will give tips and tricks on how to keep and carry patients’ medical records in the most efficient and most convenient way possible.  Medical records may be bulky and voluminous.

ROJ@65@14mar2

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