- Indian Rheumatology association
We all must have wondered at some point in time to document our patient’s health records in our clinics. However, due to various reasons (logistics, manpower involved, additional expenses, comfortable in existing way of practice), it tends to get ignored. However, it may not be so cumbersome after all. Just a little nudge away from procrastination, and we might actually be able to include this in our daily practice.
Proper documentation should include but not limited to the following
Good documentation strategies lead to safer & better patient care, higher patient satisfaction, increased clinician productivity, and may avoid medico-legal issues in the future. Also, the National Medical Commission (NMC)’s 2023 regulations for registered medical practitioners (RMP) include maintaining patient visit records for at least 3 years after the last consultation.
For brevity, we will focus on maintaining patient data and records in individual doctor clinics.
This can be done manually by reception staff. A better way in today’s era would be to use comprehensive clinic management software (see table) or at least a software (eg; DaySchedule) which can send automated appointments, cancellations, availability, or other messages.
Patient should be guided to fill out registration forms which include name, age, sex, address, contact details, emergency contact numbers, and source of their referral. This form may also include a column for short patient history or presenting complaints which can be accessed later by the treating doctor. These data can be scanned in individual patient folders or maintained in an Excel sheet or using a clinic management software (CMS).
This should be the most important focus of documentation in the clinic and as mentioned above, it’s imperative for us to store this record for the future. The following table summarizes available methods, examples, their pros & cons, and some useful suggestions.
Methods | Pros | Cons | Additional suggestion |
Manually write, scan, and save Scan all the written prescriptions, reports etc., and save a soft and /or physical copy | Easiest way, No additional costs Replicable in most settings Minimal concern about data misuse and loss | Cumbersome to retrieve fine data points. Functionalities will be limited compared to clinic management software’s (CMS) | Use a mobile phone scanner Can save data on the cloud (e.g. Google drive) in individual patient-named folders |
Automatic text expander A single or defined set of words is used to generate a fixed set of paragraphs, prescriptions templates etc. & rest data filled on a personal computer (PC) | No additional cost Minimal concern about data leak, misuse, and data loss. Patient datasets can be retrieved by simple PC | Need to feed templates and sentences based on text. Need a printer Functionalities are limited compared to CMS | There are inbuilt text expander facilities in Apple IOS and other software’s also available. |
Pen and Paper based digitization software Prescription sheets are digitized as written (based on special customized paper and Bluetooth pen) Eg : Doxper (meddo), Wondrx etc | No behavioral change is needed among doctors used to writing Customization of letterheads & prescription sheet Boxed datasets can be retrieved on an excel sheet Patients can get automatic messages of prescription copies, follow-up appointments, article links etc | Chargeable fee Need to carry paper and a bluetooth pen. Need reliable service from the concerned software provider Theoretical concern on data leak, misuse and data loss. | Ideal for a medico who sees patients in different settings and doesn’t want to type. Also, as written data is saved in pen memory, continuous internet availability is not required. |
Complete clinic management software – CMS (cloud based) Eg : healthplix, solomo 360, rheumato software by healthlink technologies | A range of advantages not possible with other mediums Easy portability with internet connection Can do appointment slotting, automated messaging, payment integration, accounting, online appointments, clinic dataset generation, pharmacy integration, staff management, etc. Machine learning makes recording history and prescriptions safer, faster and can generate multi-linguistic prescriptions Range of customizations feasible e.g. disease activity score calculators, automated advice, letters etc. Data retrieval for research can be much easier Data can be backed and exported Most software’s should be abiding government directed data protection guidelines | Chargeable fee, but usually very cost-effective Need continuous internet availability and printer set up Theoretical concern on data leak, misuse and data loss Need reliable service from concerned party. Company shutting down operations is always a risk. Very difficult to integrate old data while switching to another platform | Find reliable company with strong financial backing as there are too many players who may not be able to sustain in long run. |
Clinic management software – personalized Software personally designed for an individual or group of doctors. Complete ownership of data and software remains with doctor. | All the advantages of third-party cloud based software’s No limit to customizations (if designed well) Minimal risk of data misuse or theft. | Can be relatively very costly, especially at start Need a very reliable app or software designer who can deliver the goods and can provide timely service updates. | Find a software developer or company with stable and sound credentials as changing developer may become a big hassle in future |
As per quote “If it’s a good idea, do it today ‘, all clinicians should start organizing and documenting data. No matter which method one chooses, starting with a certain method gives perspective and than can improvise based on experiences. Talking to a colleague who has experience in clinic documentation can also help.
I have personally used Doxper (meddo), Rheumato (by healthlink technologies) and currently using Healthplix software. The above-mentioned names are only given as examples and there are multiple such software’s or apps. I don’t have any affiliation or conflicts of interest with names so mentioned. One should do their due diligence before subscribing to any relevant services.
