ROJoson’s Project Patient Medical Records – Initial Conceptualization

Project Patient Medical Records

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

Conceptualized in March 2, 2014

A Project of ROJoson Medical Clinic

A ROJoson’s Legacy for the Filipino Patients

Introduction:

A person will unavoidably have concerns with his health during his stay on earth. He must have records of his health, either created by himself or his guardian (diary of symptoms) or by a health care professional or provider.  All these records constitute his medical records, or patient  medical records, which can be broadly classified as those from the health care providers and those from his own or his guardian.

The medical records from the health care providers can come from the physicians, other health care professionals, medical centers or hospitals, and clinics he has consulted.

The medical records from the non-health care providers can come from diaries of symptoms made by himself, if he is capable, or his guardian, if he is not capable, such as during his childhood or when he become incapacitated.

These patient medical records are important in a person’s health management during his stay on earth.  They facilitate management by the health care providers.  Past medical records are routinely asked by the health care providers when they manage a patient.   The past medical records, if present, facilitate assessment of the patient’s current health concern as they can provide clue to the diagnosis of the patient’s health condition.  The past medical records also facilitate decision-making on diagnostic tests and treatment.

Aside from facilitating management by the health care providers, the patient medical records can also facilitate personal health management by the person himself or by his guardian, especially, if the latter are taught and empowered by their health care providers.

For the abovementioned reasons, I deem it a must for all persons in this earth to establish and develop a system of making, keeping, and maintaining personal medical records and to ensure their accessibility at all times.  It is important to have the patient medical records readily accessible as it has impact on the timeliness and correctness of the decision-making in health management, particularly during emergencies.

Starting today, I will conceptualize Project Patient Medical Records from the point of view of the patients, not from the point of view of the health care providers.

Actually, I began actively advocating patients keeping their medical records as early as 2000 or even earlier (I am still trying to gather evidence to get the exact year at least) when I started giving my patients a duplicate copy of my clinic notes and explanation.  In June 2011, when I started using Facebook for my Education for Health Development in the Philippines Program, one of the first notes or advisories I published was the following:

ROJOSON Advisory: Always Keep a Copy of Your Medical Records

July 9, 2011 at 7:05pm

All human beings should keep a copy of their medical records throughout their lifetime!

They should develop a habit and a system of keeping a file of all their medical records. 

 

The records will come in handy when they are needed for medical consults and medical clearances in applications for job, insurance, migration, etc.

Patients: 

DO NOT LEAVE ALL YOUR MEDICAL RECORDS WITH ANY DOCTORS YOU CONSULTED! Make sure you have a copy, preferably, an original copy. In the future, you will have difficulty getting your medical records from your doctors. They may be lost in your doctors’ clinics. Your doctors may die with your records. You may be shy and afraid to get your medical records from your initial doctor when you want to go to another doctor for a second opinion.

Doctors:

ALWAYS MAKE SURE YOUR PATIENTS HAVE A COPY OF THEIR MEDICAL RECORDS IN THEIR POSSESSION! Do NOT get all their medical records without them having a copy.  Encourage them to develop a habit of keeping a file of their medical records.

Since then, I have been constantly reminding the public on the importance of keeping their medical records.

See links below:

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

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

In Project Patient Medical Records, I will expand what I have started before.  The key areas to cover will be the following:

  • How to make the patient medical records
  • How to keep the patient medical records
  • How to maintain the patient medical records
  • How to make the patient medical records readily accessible when needed

I will develop each area one by one independently initially with an awareness that there will interfacing among them and there is a need to align and integrate in the long run.

Target completion date: Not later than June 2014.

ROJ@65@14mar2

This entry was posted in Keeping Medical Records, Project Patient Medical Records. Bookmark the permalink.

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