Difficulties faced by a G.P.

G.P. has to work single handed. He does not have a well educated clerk to assist, where as maintaining and finding back records is a clerical and time consuming work.

Many of the patients are occasional visitors of the wanderers. They never come back within a reasonable period of time. So time spent to write such casepapers appears as a waste of Doctor’s valuable time.

Most patients in General Practice have minor complaints, like influenza pharyngitis, minor pains etc., where maintenance of records of every patient that he sees!

Some specific patients require maintenance of proper medical records.

Patients with chronic illnesses like Diabetes, Hypertension require a proper record of treatment taken and investigation reports or B.P. – over several years.

Patients who are allergic to certain drugs must have a proper record. Otherwise the same drug to which allergy is known, may be repeated after a few months or years

The families who always come to you their records must be properly maintained, especially the children. eg. Parents of a 5yr. old child might want to know whether M.M.R vaccine was given by you in the first year. Without records, you may have no answer!

SYSTEM – 1 : CASE – PAPER SYSTEM

The most common practice amongst General practitioners is of not keeping any records!! Ignoring that, the most common and useful method of keeping records in General Practice is maintaining case-papers which are arranged surname- wise

They are kept according to surnames from A to Z, and within each group, papers of each family are bunched together – pinned or clipped. So, if you take out paper of say Mr. Eknath Patil, then all papers of his family will also be received together if any member of his family comes to you, you have to take out his file. This will help you to keep full & perfect records of the 40-50 or more families which are under your regular care. Another advantage of this system is in preparing ills. As all bills of that family will be paid by the same person, it is easier to add up all dues, Plus, the bills submitted, dues & paid, will also remain written on the main paper for future reference.

A sample format of case paper is given below:

On the case paper, summary of signs, symptoms or diagnosis are written in very few words, and n treatment column, only names of drugs will be mentioned. Detailed prescription is written separately to be given to the patient.

In this system, every year end, papers should be scanned, papers of patients who will not come again are discarded and only regular patient’s papers carried forward to next year.

SYSTEM 2: REGISTER SYSTEM

This system is more useful for floating patients. In a regular long book, make columns as shown on left side

When a patient comes again, ask him when he had last visited you. Approximate Date or date on previous prescription allows you to quickly find his last one visit’s record. But multiple visits are difficult to trace.

If the patient does not remember the date, then it becomes difficult to find it from the name. The second problem is that you cannot write in a register in front of the patient. It does not create a good impression. So you have to write on the prescription and then as the patient goes out, enter in the Register.

Oh no! I have no time for paperwork.

Keeping records means lot of paperwork. No doctor likes it. No doctor has time to spend on it. So Most Doctors do not keep any records. Medico-legal cases like CLWs, injuries, burn etc.

Since both systems of keeping records are not perfect, a combination would be more appropriate. Case-papers for regular Family Patients & chronic illnesses. Plus Register for occasional patients.

SYSTEM3: CASEPAPER WITH PATIENT

Another method followed y some practitioners is to give the casepaper to the patient. A sample of such casepaper is shown here. But not keeping any records at all is also not correct. If any medicolegal problem or compensation claim arises, you could be in trouble if you have no records. The beast alternative is to keep record of at least the few important cases and all potentially write the complaints and diagnosis on left side, and on the right side, write full detailed prescription & instructions. Instruct the patient to preserve the paper carefully & bring it everytime.

Note:

1. Good quality paper must be used, as patient will handle it often.
2. Instruct regular & chronic patients to buy a file & keep your casepaper, investigation reports everything together.
3. You have to write with care, an it will be read y threaten & other doctors wherever he goes. So you cannot afford to write carelessly or make mistakes. For the patient, this is a better system, as all records are available to him, and if he goes to another town or another doctor, has previous treatment are with him. But if patient is uneducated, he may not preserve the papers and everything may be lost1.

From patient, this is a better system, as all records are available to him and if he goes to another town or another doctor, his previous treatment are with him. But if patient is uneducated, he may not preserve the papers and everything may be lost!

From doctor’s point of view, the system keeps no records with him. The documents which are legally his remain in patients hands. And course, he becomes open to criticism, if he has missed any finding! Yet, some good practitioners do follow this system.

Another very nice practice, often followed in government dispensaries, is to ask patients of chronic illnesses to buy a small pocket Note Book (Patients of Tuberculosis, Diabetes, Hypertension) so that regular records of weight, BP, Urine sug etc. and the treatment, will be maintained. Even if some other doctor continues to see the patient in future, he will have the records and may as well continue to write in the same book.

SYSTEM 4: COMPUTERS

Though today, computer is not within the purview of common General Practitioners, some practitioners have started using it, and very soon, it will be a part of General Practice, especially amongst the new generation, who will be conversant with computers from their school days. Let me now discuss how computer will help a General Practitioner.

The computer programs will be of two major parts:

I.                     Records oriented.

II.                   Symptom Oriented.

Record Oriented Program:

It will have advantages of both – case paper system and Register system.

Once the patient’s name, age, weight & address is fed in by the Doctor or his assistant, the Doctor will type only the complaint, Names of drugs advised and bill.

Prescription:

-          The prescription will be typed out in full details with all instructions that the doctor may otherwise not write.

-          The doses of drugs will be age and weight related, or as desired by the doctor

-          There will be a choice of local language in which the instructions are printed.

-          If drugs do not match, it will be indicated eg. Tetracyclin and Antacid,

-          If drugs do not match the diagnosis, computer will show a warning. Eg. If steroid is prescribed to a patient of Hypertension or Diabetes.

-          Allergies, once fed in the computer, will always be reminded everytime in future.

Bills & Dues:

-          Compilation of Bills & Dues, which takes up a significant time of the G.P.s at monthends will be a minute’s job. A list of all the dues may just be printed out and handed to the compounder for collection every month.

Tracing out old records, of all the visits of the patient, will be very easy from the patient’s name/number.

Writing of certificates will be very systematic and quick. Only the diagnosis and dates of illness & fitness will have to be typed.

Academic minded G.P.s will have statistics at their fingertips. Today many General Practitioners are writing papers on those aspects of diseases which are missed/never seen by researchers in Hospitals.

At the year end, all records may be copied to a floppy for storage. Then all unwanted records deleted from the main computer hard disc and only important ones carried forwards to next year.

Symptom – Oriented Program

This program will be a systematic compilation of Medical knowledge.

It will help the general practitioner in tackling difficult cases, not responding to routine treatment.

When data on such cases is fed to the computer it will suggest all the various possibilities, suggest investigations and Differential Diagnosis.

Also it will help the Doctor to revise his knowledge from time to time and freshen his thinking process.

Let it be clear that the computer does not think for the Doctor! It just helps the Doctor in his thinking process. So if you can take the right advantage of it, in selected cases it will be a great help. Because, it will combine reference of many books for you.

Internet:

Internet is a worldwide network of computers, which gives you access to any information anywhere in the world. If you just give a topic, say malaria, you will get an access to practically all latest research papers, current accepted lines of treatment, al drugs and  anything that you may not offer!! And what a radical change will it be, from the present situation, where the General Practitioner has no access to any books other than the few undergraduate books that decorate his showcases!