An Integrated Systemfor the Recording and Retrievalof Medical Data in a Primary Care Setting

Part 8: The Individual Patient's Medical Record

Donald F. Treat, MDRochester, New Y o r k

This is the last in a series of articles describing an integrated system of recording medical data as developed and used by the Family Medicine Program at the University of Rochester-Highland Hospital. Previous articles have described the age-sex register, classification of diseases, a diagnostic index, family folders, filing records by census tract, problem-oriented records and encounter forms. The system allows the practicing family physician to assess morbidity patterns within his practice more effectively, to record and monitor patient care, to perform audit and to conduct research in primary care.

There are many variations in the form and style with which physicians record their observations of patients. To date, no conclusive proof exists to indicate that the method of recording observations makes any significant dif­ference in patient care outcome. Nev­ertheless, as Weed1 cogently pointed out, principles of order, discipline, and systematization are present in the vast majority of productive, worthwhile human endeavors in scientific or artis­tic fields. There is reason to believe that a framework of order, discipline, and systematization for medical re­cords would be equally worthwhile.

In designing our medical record

f rorn ttie F a m ily M e d ic in e P ro g ra m , U n iv e r- s ltV o f R o c h e s te r -H ig h la n d H o s p ita l, Hochester, N e w Y o r k . R e q u e s ts f o r re p r in ts should be addressed to D r . D o n a ld F . T re a t,

amily M e d ic in e P ro g ra m , U n iv e rs ity o f Rochester-Highland H o s p ita l, 3 3 5 M t V e r- non A ve, R o ch e s te r, N Y 1 4 6 2 0 .

forms for the individual patient, we had the following objectives. The indi­vidual medical record should:

1. Allow rapid and accurate identi­fication of the patient.

2. Facilitate recording and retrieval of data.

3. Be problem-oriented rather than source-oriented.

4. Permit rapid horizontal scan­ning.

5. Allow for meaningful review and audit bya. displaying data in a system­

atic mannerb. encouraging the recording of

clinical reasoning.In order to meet these objectives,

an individual patient’s record must contain the following elements: ade­quate data base, problem list, initial plans for each problem, and progress notes (reader is referred to Part 6 in this series entitled “The Problem-Ori­

ented Medical Record” by Jack Froom, MD). Except for the problem list, these elements are arranged on color-coded, standard weight 8V2 X 11 inch paper. The sheets of paper are sta­pled together to form an individual re­cord.

Because periodic assessment of growth and development, and anticipa­tory guidance are such important parts of a child’s medical care, a different form seemed essential for them. Also, in order to facilitate location of the proper individual record within the family (household) folder, we arbitrar­ily selected green front sheets for males, yellow for females. The problem list is treated somewhat differently, as will be described later in this article.

Figure No. 1 represents the front sheet o f an Adult's Individual Medical Record.

1 A. Contains space for the follow­ing demographic data:

THE J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1, 1 9 7 5 4 3

Name, date of birth, place of birth, date first seen, census tractAddress, telephone number(s) Occupation of head of house­holdOccupation of self Billing information Ethnic Group (C N I O), Education (Hs C PG),Religion

IB. Place for recording family his­tory and past medical history.

IC. Space on front sheet for re­cording critical, important in­formation on the individual patient, such as names of other physicians involved in the patient’s care, type of operations performed, reason for hospitalization (if not on problem list), allergies, drug sensitivities, smoking history, and, for the female, the men­strual history.

Figure No. 2 illustrates the front sheet o f a Child’s Individual Medical Record.

2A. Demographic Data - name, birthdate, census tract, date en tered program, ethnic group, social security num­ber.

2B. Immunization and Screening Schedule Sensitivity (aller­gies, drug idiosyncracies) — The heavy lines indicate rec­ommended ages for the ad­ministration of immuniza­tions or screening procedures. If the child receives the im­munization at the recom­mended age, a check (V) is placed in the appropriate box. In other circumstances, a date (month/year) can be entered.

2C. D evelopm ental Milestones and Anticipatory Guidance — The importance of moni­toring the physical and emo­tional development of chil­dren is a well-accepted tenet of good medical practice. Be­sides allowing the physician or nurse practitioner to re­cord the age at which the child passed his develop­mental milestones, this grid also indicates when 90 per­cent of normal children can be expected to achieve cer­

tain motor, communication, and social skills. In an adja­cent section appear anticipa­tory guidance items which remind the health provider of areas to be covered with the parents.

Figure No. 3 shows the reverse side o f the A d u lt’s Individual Medical Record Front Sheet. This section con­tains a grid for recording immuniza­tions, a grid for recording when se­lected screening procedures were per­formed, and space for a brief state­ment about the patient’s personality, coping characteristics, and life style.

Figure No. 4 shows the reverse side o f the Child’s Individual Medical Record Front Sheet.

4A. Space for recording signifi­cant data about prenatal pe­riod, delivery and condition at birth, early developmental problem s, and behavioral problems.

4B. A grid for recording the child’s previous illnesses and the occurrence of possible he­reditary disease within the family. Space is also provided for narrative elaboration of additional health history and for noting names of others who are sharing in the child’s care.

Figure No. 5 illustrates the Labo­ratory Data Sheet (white). This is a flow sheet to facilitate the orderly recording and rapid retrieval of labora­tory results. Blank spaces are provided to permit insertion of additional tests when indicated. The same grid is dupli­cated on the reverse side of this form.

Figure No. 6 shows the sheets designed to accommodate laboratory report slips from the office lab. These are placed behind the front sheet and laboratory flow sheet. The slips are glued on in shingle fashion. These sheets also have a distinctive color to facilitate their location.

Figure No. 7 illustrates the Cum­ulative Problem List. Across the top are places to record the patient’s name, date of birth, and census tract. Each health problem — whether a symptom, an abnormal laboratory re­sult, a social problem, or a confirmed diagnosis — is placed on the problem list when the problem is believed to have possible long-term health implica­tions for the patient. The date when

the problem is entered on the list js also recorded, together with the diag­nostic code number for that problem The same code number then appears in the progress notes whenever that prob­lem is considered again. Columns are provided for recording when problems are resolved and for titles of inactive problems.

Figure No. 8 shows the reverse side o f the Problem List. This is the patient’s medication record, both long­term and short-term. When the medi­cation record becomes filled, addition­al forms can be stapled to the Problem List.

The same Laboratory Flow Sheets and Problem Lists are used for chil­dren. In contrast to other parts of the individual medical record, the Problem List/Medication List is never stapled into the record. Instead, it is com­posed of heavier paper stock and “floats” immediately in front of the latest progress notes. This arrangement allows the physician to easily extract and refer to the problem list for diagnostic information, code numbers, and current medications, and generally reduces the amount of time otherwise spent turning back and fourth between problem list and progress notes.

Figure No. 9 shows the Form for Recording Progress Notes (both child • and adult). This form is designed to promote rapid horizontal scanning of progress notes. When the physician places a V beside an organ or region examined and found normal, or an X beside an area found abnormal, a sub­sequent reviewer can easily locate this information by scanning the chart and focusing on a particular number listed in the center section. Frequently data on heart murmurs, breast examina­tions, and ophthalmoscopic examina­tions are located in this fashion. The health provider records notes in two vertical columns on each side. The history of current illness, review of systems, physical examination, etc, can be recorded in either the tradi­tional or problem-oriented fashion. Our strong preference is for the latter. If the progress notes are typed, the last notes are not stapled into the record until both sides and all four columns have been used.

Reference1. W eed L L : M e d ic a l R e c o rd s , M edical Ed­

u c a t io n a nd P a tie n t C are . C leve land, The Press o f Case W e s te rn R eserve , 1 969 .

4 4 T H E J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1, 1975

Name --------------------------------------------Date First Seen Date of Birth

Place of Census

Address C O D E Telephone No. Home: Work:Social Security No.Occupation: Head of household Place of Employment of Payer:Occupation: Self AddressWhom to B ill:Type of Med. Ins.:Contract No. Group No. Class No,

.Education:__________HS. C. Prv

Family Hx. D A T E State of Health

Father’ Mother

Pat. g. f-q. m.

Mat. g. f.g. m.

SpouseSiblings

Children

Have you or any relative (blood) or husband or wife had :

Self Rela - five__ Relationship

o°DiabetesCancer

AnemiaGoutKidney DiseaseHigh Blood Pressure

Heart Trouble

Bleeding DisorderAsthma Hay FeverEpilepsy SeizuresMental RetardationMalformation

Neurologic DiseaseStroke *BlindnessThyroid Problem

DeafnessVenereal Disease

Mental IllnessStomach or Bowel ProblemsRheumatic FeverT uberculosis

Arthritis Selfno yes

Operations Mi m pHospitalization Chicken PoxInjuries Rubella (3daymeasle)

Hepatitis-Jaundice Scarlet Fever

Pneumonia Pol ioTonsi I it is Tendency to infectionMeasles

REMARKS: (Critical Information)

Menstrual History: Menarche------ ; Frequency------ ; Length--------

Cramps----- : C lo ts ----- : G ravid— ; para— ; ab --------

Weight of Heaviest Child

Smoking History: Age Started— Cigarettes — Pipe — C igars---------

Age S topped_____________ Q u a n tity ________________Reason for Stopping_______________________________ pack'yrs. —

ALLERGIES:

F ig u re 1 B . © Family Medicine Program, R oches te r 1 4 6 2 0 F ig u re 1C.

F ig u re 1. A d u lt 's In d iv id u a l M e d ica l R e co rd

THE J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1, 1 9 7 5 4 5

Fe

ma

le c

hil

d

L a s t na me

D a te e n te re d P ro g ra m

E t h n i c G ro u p

F i r s t B i r th□ x i

CT

So urce SMA ft_

Soc. Sec. ft

Figure 2A.

S E N S I T I V E T O :

I M M U N I Z A T I O N A N D S C R E E N I N G

D P T Sa b in M e a s l e s M um p s R u b e l la H c t U / C T ine H e a r V i s i o n L e a d Mi sc

Mo: 2 S i c k l e

4

6 G 6 P D

9

12 ______ L_18 S in g le im m u n i z a t i o n s

Yr : 2 D a te V a c c i n e

3

4 _____ 1______5

6

8 D T

10 o n c e

13

Figure 2B.

DEVELOPMENTAL MILESTONES B 3 mo. 6 9 12 15 18 ANT 1C IPATOR Y GUID ANC E

W a tche s fa c e x |_ 1 [ J F i r s t s o l i d fo o d s

] F l e x i b l e f e e d in g s c h e d u l e s [ ] T h u m b s u c k in g

IX] S le e p in g p o s i t i o n s and h a b i t s [ ] S a f e ty — p u t t i n g s m a l l t h i n g s in mouth;

S i b l i n g j e a l o u s y c a n a s p i r a t e b e a n s , p ea n u ts , etc.

C o o s ; f o l l o w s m o v in g o b je c ts 1L a u g h s

H o ld s hea d e r e c t xP u ts t h in g s in mouth 1 ] S le e p s c h e d u l e | | W e a n in g to c u p — d e s i r e t o ke ep bott le

[ J H a n d l i n g o f g e n i ta Is j | S a fe ty - c r a w l i n g g iv e s a c c e s s to pins,

h e a t e r s , e l e c t r i c o u t l e t s , med icines

a nd p o i s o n s . S ea t b e l t s .

R o l l s ov er

S i ts w i t h o u t s u p p o r t ~ TP la y s p e e k -a -b o o ; C r a w ls

P u l l s up to s t a n d in g x X I A d v i c e on sh o e s 1 1 T e e t h i n g [ R e d u c e d a p p e t i t e | ] D i sc i p i ine

[ J S a f e t y — c 1 im b in g g iv e s g r e a te r access

t o h a z a r d s ; w i n d o w s , s t a i r s

[ 1 N u t r i t i o n ; t e e t h ; re d u c e d a p p e t i t e ; sweets

T r i e s to e a t w i t h f i n g e r s TWave s g o o d b ye

Walks w i t h o u t s u p p o r t XC l i m b s on fu r n i t u r e

] D e s i r e t o do th i n g s for h im s e l f

T r i e s t o us e c u p and spoo n

S pe aks a f e w w o rd s

W a lks up and d ow n s t a i r s 1 [__ j B l a d d e r and b o w e l c o n t r o l

] A c t i v i t y and naps

[ ] N e e d t o p la y w i t h c h i l d r e n own age

] A n s w e r i n g sex q u e s t i o n s

U s e s th r e e -w o rd s e n te n c e s

P la y s a lo n e ; ‘ h e l p s ’ c l e a n h o u se

A s k s “ w h y ? ”

U s e s f u l l s e n te n c e s

P la y s c o o p e r a t i v e l y

D e v e l o p s b la d d e r and b o w e l c o n t r o l ] B la d d e r a nd b o w e l r e a s s u r a n c e

[ ] S a fe ty — a u to m o b i les , f i r eD r e s s e s s e l f

Drop s i n f a n t i l e s p ee ch p a t te rn s

V IS IT S A D A T E S :

3 3m o . 6 9 1 2 15 18 21 24 3 y r . 4 5

© Family Medicine Program, R oc hes te r 1 4 620

Figure 2C.

Figure 2. Child 's Individual Medical Record

46 T H E J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1, M

Date of Immunization

Diphtheria

Tetanus

Pertussis

„ SalkSabin

SmallpoxTyphoid’ s Para.

Influenza

Measles

Rubella

T est

Skin Test Da,eResult

SCREENING PROCEDURES

DateChestX-ray EKG

Tono­metry

H ct.Hgb.

BloodSugar V is ion Hearing

C ervicalPap Breast Prostate Sigmoidoscopy

19

19

19

19

19

19

19

19

19

Child: D escription of B ir th , n eo -n a ta l period, growth & development: Adult: B rie f d escrip tio n of in d iv id u a l & l ife s ty le ( w ith d a te ) :

Figure 3. A du lt's Individual Medical Record (reverse side)

THE J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1, 1 9 7 5 47

HEALTH HISTORY

B IR T H A N D N E O N A T A L P ER IO D :

M o th e r ’ s h e a l th d ur ing pregn an cy :

D e l i v e r y and c o n d i t io n at b i r th :

W ............. L ... A PGA R /

1 min 5 min

N e o n a ta l p er iod :

D E V E L O P M E N T A L P R O B L E M S :

E M O T I O N A L A N D B E H A V I O R P R O B L E M S :

CHI LD F A M I I YYes No Code Code Y es No Kinship

110 P e r n i c io u s A ne m ia

112 Othe r f a m i l i a l anemia

211 H e a r t a t t a c k ; ang ina 212 812

155 Stroke 822

218 H y p e r te n s io n 813

091 Dia betes 807

093 Gou t (h yp e ru r i ce m ia ) 810

086 A sthma 802

085 H a y fe ve r 811 ‘—

- C a n ce r (by region) 805 ' ■158 F i t s or c o n v u ls io n s 809

- B ir th d e fe c ts (by type) 825

- Me n ta l i l n e s s (by type) 818

012 R u be l la (German m e asles) 825

016 J a u n d ic e 815

210 Rh eu m a t ic feve r 821

003 S y p h i l i s - - GC 004

T e n d e n c y to i n fe c t io n

- Ch i cken p ox A l s o under care of:

- Meas les

- Mumps

- S c a r le t fe ve r

- Whoop ing cough

- T o n s i l i t i s

- Pneumon ia

F ig u re 4 B .

A D D I T I O N A L H E A L T H H IS T O R Y : ( i l l n e s s e s , a c c id e n ts , h o s p i ta l i z a t i o n s , o pe ra t io n s , e tc . )

PSYCHOLOGICAL FACTORSF A M I L Y P R O F I L E

F ig u re 4 A .

F ig u re 4 . C h ild 's In d iv id u a l M e d ic a l R e c o rd (reverse s ide)

4 8 T H E J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1, 1975

(c) Fam

ily

Medi

cine

Pro

gram

, Ro

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ter

1462

0

LABORATORY DATA SHEET

DfiTE _______________ NORMALS (KCRL)

BUN ~ 7-25--------

Cholesterol 150-300Lipids 400-800Triglycerides 0-160

C0? 20-32(meq)Na 135-148Cl 96-107K 3.5-5.5

Glucose @/ hr. - L / / / / / / / / / / 70-110/F

T^ Uptake 25-35%Td (M-P) '2.9-6.5-------PBI 4.0-8.5

Uric acid 3.0- 8.0 M2.0- 7.0 W

DATE NORMALS

ASO titre roou

Bilirubin, direct 0.0-0.2" , total 0.1-1.0

Calcium 8.5-10.6Phosphorus '2.5-4.5

Creatinine ol ■nj! 1 H Ol

" clearance 105-150(H.H.)

Glucose Tol: F 60-100(H.H.)1/2 hr. 1601 hr. m e2 hr. 1203 hr. 100

Proteins, total 6-8.2Albumin 3.5-5.5Globulin 1.5-4.0%

• 1 3.5-10%.. 7-15%II 10-20%

Rheumatoid factorANFLatex

SGOT 5-40LDH 70-225

(H.H.) = Highland Hospital Lab Normals

Figure 5. Laboratory Data Sheet

THE J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1 ,1 9 7 5 4 9

FAMILY MEDICINE LAB REPORTS

H H 139/2 d( R E V . 10-73) _ /

S j v l t k£ i Q _ L .

Name J-D octor ± / Q J d £ S - U&JtCensus

H E M A T O L O p Y

□ h«□ WBC _

□ D iff :

-------------------- Segs

______________Lymphs

____________Monos

____________ Eosins

____________ Basos

____________Bands

M orphology:

FAMILY MEDICINE REPORTU R IN A LY S IS

t □ Appearance ___

C-_____________ □ Sp. Gr. / * _ O J S - _____

□ pH _ ^ £ y _ 0 --------------------

□ B lo o d _____/V & L _______

□ A lbum in __ _______

□ G lu c o s e -----L2YJlA-J>----------□ I c t o ---------------------------------------

Q M ig ro ^ // jwbc

____ 5l _ rbc---------------- Epi

--------- ------ ---Bacti

Casts: — 0 ------------------------

Date— .

M ISC ELLANEO US

□ Wet M o u n t __

□ K O H __________

□ Preg.test _____

□ M o n o s p o t____

□ ESR___________

□ Gram s ta in ____

□ U r i c u l t _______

Crystals: .

□ Throat C ulture:

Beta S tre p _____

Group A _____

Pt.'s p h o n e _______

R x . _____________

By:

Index

H U1/

Tape first slip to this line

Tape bottom of report slip to this line

<u0)&

&•HrHOjCOP,•H

Tape bottom of report slip to this line

oCOQ)bjO

tjd)-p

£

Figure 6. Laboratory report slips sheet

5 0 T H E J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1, 1975

PROBLEM LIST

iJBLi T f£Last NameJ 1 g / K

Given Name Q \ o \ tCT

HATEDIAGNOSTIC

CODE PROBLEM TITLE DATERESOLVEI INACTIVE

/ / / a / - / ? « - o l 3 ' ' / / a Je+iQ / 1* /c.i>L.

*J?o h u rUtfo./ V/ao J C f * * - G?t)

----f-L------

■ / / l -- r - J / ^/ o h a c c o a » ^ s ' € --------------- ? r/r»

i/?o / * / . (9l>ese~f-y______________

T—------

i v y ' '/'l* € 7 T ~3. Ciry\l/S\.i~S ' -?fA /

/ T i ? __ 9 Irt'f&l doto.J-/(c ’6 ~----r— —

* u/ n

%/?3 r /J 1 ------------------

T ) f a. i> e 4--e-S M z f / ' /b s

"-'

V''

04 J Y i tt 0 l*A i 1 fe. — — ------------ ^ /* fiy

lllL . 7 -3 / d / e s ~ { P a ^ i 4 — ------------- 7

A.}6 _____ /fff« / tr ________________/ 1 {J

Figure 7. Cumulative Problem List

THE J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1 , 1 9 7 5 51

© F

amil

y M

edic

ine

Prog

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, R

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ster

146

20

Figure 8. P

roblem L

ist (reverse side)

MEDICATION RECORDDrug Allergies, Intolerances, Idiosyncracies, Abuses: Well-tolerated and Effective Drugs:

LONG-TERM MEDICATIONSDATE DIAG

CODEPROBLEM TITLE MEDICATION DOSE SIG AMT

RXdREFILL INSTR SUBSEQUENT REFILLS

(Date / amount or cutoff date)

DATE CODE MEDICATION DOSE SIGSHORT-TERM MEDICATIONS

AMT REFILL DATE CODE MEDICATION DOSE SIG AMT REFILL

Enc. Form No. : 9 7 4 6 4

Date A / 1 ? /7 4 Time q -3 0 A Place MPTTT 37 p 78___ BPL A (/q5___wt 184

STAT Lab:___________________________

HOSPITALIZATION Adm: Disch:ER Visit:

NAME SMITH, J o h n Enc. Form No. : 9 7 9 2 0

Ht-------------------- Date 7 / 1 4 / 7 4 T im e] i ; ooA5 ' 5 " T 3 7 2 p 80 B F l3 7 /84_____________ STAT Lab:

plac~e MPU W1 184 HI 5 ’ 5"

P.091 - Diabetes MellitusS. No increased thirst or polyuria.

Meds: None for 91O. Fundi: Negative

Peripheral pulses O.K.2° pc blood sugar 150

A. Reasonably good controlP. Continue 1200 cal. A.D.A. diet.

P.091 - Diabetes Meljitus S. No sumptoms.

Random urine tes-tapes always Neg.O. Office U/A

Negative glucose & acetone A. Good control.P. No change.

Repeat blood sugar, next month.

oCMVO

ua)-p(0Q)£Oo

uW)ouOh<D•HO•HTfQ)gr—1 •HOn©

P.101 - ObesityS. States that he is following

diet.O. (1) overweight, 134#

No change in 3 weeks No edema

A. Probably not following diet.P. Detailed discussion about

diet. Ret. 1 month.

P.230 - AnginaS. No pain or dyspnea

Taking med. as directed.O. No change in ECG since 1/74.

Heart tones W.N.L.A. StableP. Cont. Isordil, exercise

plan and weight reduction.

Dr. Jones

0G p n . App.

M e n t . S t a t .1 a

V S k in

N o d e s

2

3 3

4 H e a d

E y e s

F u n d i

E a r s

N o s e

O r a l

T h r o a t

4

k ' s 5

Y 6 6

7 7

8 8

9 9

10 10

V f i N e c k 1 1 -12 C h e s t

B r e a s t sL u n g s

H e a r t

12

13V 14V 15

V 16 A b d o m e n

B a c k

16

17 17

18 E x t . G e n . V a g . & C x .

P v . C o n t e n t

R e c t a l

1819 19

20 20

21 21

2? E x t re m .

P e r i . V a s e .

22

V 23 23

24 C e r e b e l l a r

C r a n i a l

D T K ’s

24

25 25

26

27 N e u r o . O lh . 27

P.101 - Obesitys. Claims he is following diet.O. (1) No change past month.A. Probably unaware of food intakep. Detailed food diary for 1 wk.

Ret. to nurse practitioner,1 wk for diet review.

P.230 - AnginaS. NoneO. None considered this visit.A. StableP. No change.

Dr. Jones

Figure 9. Form for Recording Progress Notes

THE J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 2 , N O . 1, 1 9 7 553