Thursday, April 27, 2006

Let's call a spade a spade

What is it with patient records? Why is it that we can never get it right? I have seen patient cards (with the tiny shorthand doctor scrawl trying to make use of every piece of the card before you have to turn it over), envelopes stuffed full of A4 letters folded in half, manilla folders that everything falls out of constantly, all permutations of colour-coding to hasten the onset of psychedelia, and electronic records where you either have to dictate everything, write everything (and then submit it for scanning), or type everything. Even worse, you have to do all three, and then you cross your fingers that the computer system doesn't go down like it did last week.

Hospital paper records have to take the cake, though. I am used to a standard filing system:
  1. Patient Registration Details
  2. Outpatient and non-admission ED notes
  3. Correspondence
  4. Investigations (Haematology, Biochemistry, Microbiology, Histopathology, Radiology and ECGs at the back)
  5. Inpatient admissions with one tab per admission (most recent at the front)
  6. Split admissions into other volumes if necessary
Not that long ago, I was in New Zealand where the histories are filed:
  1. Volumes split by time period if necessary
  2. Outpatient Notes (including correspondence)
  3. Inpatient Notes
  4. Investigations filed as they occurred during the outpatient or inpatient progress
  5. No specific operation notes, all op notes written in progress notes
Needless to say, I found it a complete mess. Every department had its own staff that would generate its own paperwork that would be inserted into the notes however they liked. Woe betide the unlucky soul who dropped a history and broke the binding!

Having a fairly standardised filing system in Australia has its advantages. I know that if I flip to the back of an admission there will always be a sheet of handwritten paper describing each operation done during that admission. If you are a surgical registrar and you do not look at the handwritten notes in a patient's history, you are in for a lot of surprises.

Unfortunately, my pet peeve for the day is the insistence on calling forms by their "MR number". I understand that the Medical Records staff like to identify each form by number so they know where to file them, but does this jargon need to extend to the rest of the hospital?

If you ask me to fill out an "MR24" how the hell do you expect me to know that you mean the drug chart? And how am I meant to know that an "MR21" is a request for OT assessment? Or that "MR15" is a Progress Note? I am much more interested in whether you can accurately fill out a Fluid Balance chart, not an "MR76"!!!

So for the benefit of any professional form designers out there, anybody who asks me to fill out an MR-something will be met with a blank stare, and "What?". I will feign ignorance until I am told what this form actually is and what it is for. As for forms that have 20 tick boxes and 30 items to circle... I circle or tick the minimum number that will get the job done (usually this involves no more than three). If your form involves more than three selections, then you will get a big black texta mark saying "This form is too complicated". And if you don't like it, you can fill out an MR69 and file it in the round filing cabinet on the floor.


Kim said...

Geeze, and I thought the paperwork was bad here, but at least there's a logic to the chart.

What is an A4 letter?

Sheepish said...

A4 is a standard size of paper used in Australia - it's somewhere between legal letter and foolscap. About the size of a 15-inch Mac Laptop.

I'd be interested how the paperwork is organised in the US.