Many practices have had success with Patient Held Medical Records.
This can be used as the key component of a GP Management Plan and Team Care Arrangement. It can act as a communication tool between all providers involved in a patient’s care – are they all ‘on the same page’?.
It can also contain information for the patient about their conditions. This can be provided by a range of team members to assist in self management.
‘A4 Document Folders’ with plastic sleeves have been used by many practices.
The Patient Held Record may contain
- the patients current problems
- medical history
- current medication list
- key goals and targets, and progress towards them
- recent results (bloods, Xrays, ECGs, spirometer readings)
- specialist letters
- a care calendar
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- information about their condition (handouts)
Doctors Grand Plaza have posted their story ‘The Blue Folder buy misoprostol ‘ to the APCC 1001 stories web site. This includes an example of “the care calendar” they have developed.
Your comments and suggestions are welcome.
Are there any pages or templates you have found useful to include in a Patient Held Medical Record?
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6 Comments
The Island of Dominica in the Caribbean has had reformation of it’s health care sustem in the early 80’s by PAHO. (Panamerican Health Organisation) The focaus is on primary care and the island is divided such that there is one nurse for every 600 patietnts and one doctor for 2000 patients.
The medical notes are completely patient-held. Every person
has a notebook for his medical notes nd is responsible for presenting his notes at each visit. If it is forgotten the notes are written on a loose sheet to be placed in the book. There are no government held medical notes.
I was amazed when I first learnt of it but was rather impressed. Each clinic keeps registries of immunizations and chronic diseases etc and each household is visited by the nurse at least twice yearly if they don’t come in.
Dominica is known for it’s great proportion of centenarians. Does this patient held note promote greater patient involvement in their health care?