An Easy Fix to Medical Record Keeping

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This blog is another opportunity to feel grateful. Thank you, dear Universe, you continue to bless me with recovery and health.

Not keeping life-changing health-related documents in a synchronized format is a big risk.

A senior Neurologist commented that he considers it as an art. Often this crucial informative document is even capable of changing the entire course of treatment.

Medical Record Keeping is very important

Personal medical record is key to managing one’s health information. It involves keeping detailed track of one’s medical history. It contains diagnostic test results, medications, clinical observations, and current health status. The aim of incorporating this streamlined document is immense. It ensures that the right information is available to the right person in an accurate manner.

I met some patients who undermined the importance of this art. They viewed it as a matter of convenience and not a priority.

I was diagnosed with a rare disease called Isaacs’ Syndrome. Isaacs’ is a neuromuscular health condition that stems from muscle hyperactivity. My lift post-diagnosis underwent a drastic change. In the process, I also discovered that I had Lyme disease. Lyme is a bacterial illness that gets transmitted through ticks. I was also accompanied by Glaucoma. Glaucoma is an eye-related disease that damages the optic nerves. And Membranous Glomerulonephritis is a progressive kidney disease.

As you might surmise, these diagnoses altered the course of my life irrevocably. Suddenly there was a lot to deal with. Dealing with chronic symptoms changed me in so many ways. Sitting on my bed, packets of pills stacked up nearby. There was a time when no option or solution kept me stable for long.

It felt like I lost myself.

Between all of this, it became even more important for me to document things for clarity purposes.

The key to Medical Record-Keeping

Medical record keeping is very insightful.

  • It gives a clear perception of conditions previously diagnosed. It also helps doctors to determine actions when approaching any new health matters.
  • A medical record can help both the doctor and the patient in their respective ways. For the patient, it contains details on one’s history and treatment plan. For the doctor, it supports the correctness of the treatment plan.
  • For the patient, it can ensure continuity in care.
  • It can be used for legal reference, in case need be.

Key challenges before learning to maintain medical recordkeeping

In the initial days, it was a challenge to keep up with my medical records in a well-ordered way. It felt as if managing records was more of a science than simply an act of discipline.

  • I carried a huge bag filled with medical reports.
  • There was so much to record that at times, I got lost.
  • It was the loss of personal knowledge that also led to inefficacy.
  • At times, I scribbled. My poor-quality handwritten notes became difficult to interpret.
  • I missed eligible information.

Organizing and Maintaining Medical Records

It was one of those afternoons when I saw a spreadsheet from my investment banking job that gave me the idea. It took me weeks to synchronize all the data. I started from my initial diagnoses, and tabulated the following information:

  • Date
  • Doctor’s name, his expertise, and other clinic visit information.
  • Results of tests or procedures, or clinical screenings
  • A history of any counseling received.
  • List of the symptoms or problems on the day of the visit.
  • List of prescribed medicines. It includes medicines taken in the past and present, including any side effects.
  • Attending doctors’ comments
  • Prescribed actions
  • It is important to have a Notes section. It could include details of anything to bring to the doctor’s attention. For me, it was the allopathic, ayurvedic, and homeopathic medicines. Also, the questions about any new findings. Also, any noticed allergies with medicines or food.

This section also included keeping track of billing and insurance documents. It is important to arrange all bills and receipts in chronological order.

The key benefits:

  • Undertaking this effort made my interactions with the doctors more effective. It enabled to gather the necessary information in one place.
  • Also, keeping a digital record of the same eliminated the headache of dealing with stacks of paper files.
  • It eased retrieving and disposing of information and aided in setting reminders. It made approaching follow-ups with the various doctors very easy.
  • Further, it ensured increased transparency between consulting physicians.
  • It was most beneficial during emergencies as it eased decision-making.
  • Recordkeeping allowed me to share information and keep everyone on the same page.
  • It avoided duplication of efforts.
  • Recordkeeping was motivational in a way to see my medical stats improve over time.

To Conclude

Effective record-keeping is the key difference between chaos and clarity.

Putting the right recordkeeping tools can make the entire patient care system effective. Activities related to diagnosis, control, and recovery become easy.

For me, it helped create a bank of evidence for the care I received during my journey.

It was a tool that provided me with effective diagnosis in the first place. Having up-to-date information about my medical history helped my doctors make informed decisions. The process ensured that I received tailored care based on my individual needs.

Keeping a record of my appointments, diagnoses, treatments, and tests saved me money. In many places, I noticed that the act reduced the need for costly retests. The art identified the probability of success for my treatments and existing conditions.

Seeing great results my parents too adopted a similar approach. Now, even they maintain their medical records and realize its benefits. Using digital tools can go a long way in easing worries about losing important records.  

A popular adage reads, ”When disaster strikes, the time to prepare has passed.”

So, I request that readers should inculcate this art as soon as possible. There is always a need for a synchronized format to avoid risks and maximize results. Focusing on organizing and maintaining your medical records can ensure better health.


The views expressed in this article are the author’s own and do not represent any kind of medical advice.

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