The Book of You: Your Medical Record

by Steven D. Blatt, MD

Ever wonder what’s in your medical records?  Have you ever looked at your whole medical record?  Have you seen your child’s medical record or chart?  You know the joke about the doctor’s poor handwriting?  Well, it’s true.  Many of us, too many of us, have poor handwriting, myself included.  We write all day long.  Let me share with you what pediatricians write in our medical notes.

In the outpatient office, there are a lot of commonalities in patient records from office to office.  There’s a section of the chart that contains insurance information and consents.  We need authorization to treat the patient and to send records to other physicians caring for your child. Every chart should have demographic information:  Who lives at home? What is in the home?  Pets?  Smokers?  Lead paint?  Family history is also important.  If a sibling, uncle, and cousin have a medical condition, someday it may help lead to a diagnosis in your child.

A problem list will contain the important diagnoses or problems that your child has faced over the years.  It is a summary or important illnesses, surgeries, and hospitalizations.  This is especially helpful with older children, because doctors and parents sometimes forget things from the past.  Allergies to medications and other drug reactions are also listed.  At each visit we also have the Medication Reconciliation form.  This lists all of the medications your child is taking.  If your child is admitted to the hospital or upon discharge from the hospital, we will use this list  to ensure we have an accurate accounting of the medications.

Pediatricians love growth charts.  Hopefully, your pediatrician shows you these at each visit.  They include graphs of the growth of your child’s head size, weight, and height.  The growth pattern is extremely important in deciding if your child is doing well.  Healthy children tend to grow well and children with illnesses tend to not follow the appropriate growth curve.

Every chart has an immunization record.  In New York State, almost every office participates in the New York State Immunization Information System or NYSIIS.  This is a great computer network whereby children’s immunizations are entered so authorized health care providers can easily access immunization records.  If you have a computerized printout of your child’s immunization record, there’s a good chance it came from NYSIIS.

There is a section for letters to and from consulting physicians, lab tests, and radiology results.  If you had care at another office prior to your current doctor, the “old” medical records will be here.

The note from the child’s visit to the doctor varies a lot from one office to the next.  All notes should contain information about the “chief complaint” which is why the patient is being seen.  This may be for ear pain, asthma, or a Well Child Visit.  We will write down patient symptoms, concerns, medications, and other aspects of the “patient history.”  The section on physical examination includes the vital signs of temperature, weight, height, pulse, blood pressure, and respirations.  A detailed description of the physical exam is then written down.  The end of the note includes the doctor’s “Assessment” or diagnosis.  The “Plan” includes orders for immunizations, laboratory tests, referrals to other doctors, and when to return to the office.

At Golisano Children’s Hospital, our outpatient or ambulatory physicians transitioned to an electronic medical record on March 6, 2012.  Many offices in the community have already made this transition.  Our system will allow every physician in the hospital to have access to a complete record of your child’s visits to any of our physicians.  We will add the inpatient hospitalizations to the same system next year.  Our system, called Epic, will allow parents and patients to access portions of their charts from home.  By this time next year, Epic will be in use throughout the University Hospital system for children and adults, both inpatient and outpatient.

Using a computer has the potential to “get between” the doctor and the patient.  Some of us may be looking at the computer screen too much or may be typing when you want us to look you in the eye.  We will work very hard to make sure that doesn’t happen and I am confident we can be successful. The other concern is that it will slow us down until we become skillful in the new computerized medical record.  This should be temporary.

As a physician who teaches students and residents, I love reading my patient’s medical records.  There is a lot of interesting and useful information in there.  I try to teach my trainees the following:

  • The growth chart is key to evaluating the patient’s health.  Let the parent and patient look at it during each visit.
  • Always check the immunization record.  Immunization administration is one of the most important things we do for children.
  • Write something non-medical about the patient at each visit.  I write about their progress in school, sports, music, etc.  It helps me remember each one as a kid, not just a patient.
  • Write down important things about the patient.  This may be about a discussion we had, a parental concern, or a plan for the next visit.
  • Read the record.  We spent a lot of time writing it and there is important information in it.
  • Write neatly so the next person can read it.  Many don’t follow this advice, but that’s ok.  Since March 6, 2012, it is all computerized.

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