Medical Recording in the Clinic

In the medical clinic, when a physician sees patients, he / she has to do medical recording or medical records.

Medical recording will be operationally defined as making records of findings, treatment, plans, and advices of a physician after he / she has managed a patient in a clinic.

How does a physician make medical records?

There are essentially two ways. These are paper-based and digital-based.

Paper-based medical recording consists of a physician placing handwritten entries on a paper which will eventually become a medical record, specifically, a paper medical record.

Computer-based medical recording consists of a physician placing entries on a computer or a digital hardware or device which will eventually become a medical record, specifically, a digital medical record.

What are the advantages and disadvantages of the two types of medical recording – assuming that a physician is computer-literate and also is capable of legible handwriting.

Legibility, easier filing, and easier retrievabiity are the main advantages of a digital-based medical recording.

Impersonality is the main perceived disadvantage of digital-based medical recording as patients usually frowns upon physicians concentrating or spending more of the patient consultation time on working with a machine rather than paper and talking to them. Paper-based medical recording is usually perceived by patients as more informal.

Ease of making entries and no technology glitches are the main advantages of paper-based medical recording. Hand-drawing, if the physician is skilled in doing so, is more easily done in paper-based medical recording and patients readily appreciate it.

Filing and retrieval of medical records are not as easy as in digital-based medical recording.

Completeness of data and information inputs into a medical records is dependent more on the competency and conscientiousness of the physician rather on the type of medical recording.

Security, confidentiality, and preservation can be equally done for both digital and paper-based medical recording. The paper medical records can be scanned and converted into digital medical records for preservation purposes. However, this requires one additional step compared to digital medical recording.

Personally, at least at the moment, I prefer paper-based medical recording in my medical clinic.

My reasons and what I usually do:

  1. Ease of entry
  2. Ease of making illustrations and drawings with explanation
  3. No computer glitches
  4. Ease of making verbal and written explanations and advices while doing the medical recording
  5. Patient appreciates the effort of hand-written entries and my explanation
  6. I have a duplicate copy which I give to the patients and I ask them to sign to signify they are properly advised; they sign an informed consent or informed refusal; etc.)
  7. I can easily scan the paper-based medical records as needed.
  8. I can easily incorporate the paper-based results of diagnostic tests and other medical records of the patients into my medical chart.

ROJ@17jan26

 

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