SOUND BITESBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6972.96 (Published 14 January 1995) Cite this as: BMJ 1995;310:96
- Tony Drummond
A teenage patient recently made a formal request to read her casenotes, a demand which now has legal force. In the event all went well: the notes were full and frank but, she agreed, were clear and largely accurate. We probably ended up with a more open relationship than before, but it made me think again about medical records.
Working in the Scottish Hospital Advisory Service, which visits all NHS services for psychiatric, geriatric, mentally handicapped, and younger physically disabled patients, I was upset by the overall standard of record keeping. I tried to foster the notion that medical casenotes should enable a new doctor to obtain a clear picture of the patient's history and recent medical problems within a quarter of an hour. Not many folders came near to doing this.
There is, of course, a danger in writing notes as an empty routine, but it is not rare to find patients in long stay hospitals who have no written evidence of having being viewed by a doctor for several years. It seems reasonable that there should be some machinery for bringing the most self effacing patient to medical attention on a regular basis and recording the fact. Even then you face the problem that many casenotescannot be read without great difficulty—a fact that ensures that they are not read at all. In the long term the pressures of communication and litigation must make typescript the norm, something which the better psychiatric hospitals have already achieved.
I was a late convert to problem oriented records but after the initial difficulties found them an admirable way of caring for patients, especially in the long term. A problem list simplifies and focuses review yet provides an aide memoire which, for instance, may prevent you from forgetting that your elderly patient with weight loss was treated for tuberculosis in 1949. I had minimal success in converting my medical colleagues to a method now in everyday use in the nursing process system.
There are few topics in medicine that arouse more emotion, provoke more vociferous protest, and stimulate more specious argument than the issue of order of filing. The storytellers (of whom I am one) believe that a clinical record should read like a book, a story beginning at the first page and recording the excitements of today on the last. The opposition is adamant that the most recent events should be instantly accessible on the top page. No agreement or compromise seems possible.
Perhaps we shall find the wishes and demands of patients deciding the shape of what we have always thought of as being “our” notes. Some, like the old lady with heart disease whom I looked after in my earliest student days, will have little opportunity to influence their content. One morning I came down to the ward and she was no longer there, her passing recorded only by a probationer's entry in the nursing report.
With the unsophisticated accuracy of the young it said: “Patient had a quiet night, died 3 am.”—TONY DRUMMOND is a retired psychiatrist in Pathhead, Midlothian