On Fri, 31 Jul 1998 00:55:37 +0100, [log in to unmask]
(Adrian Midgley) wrote:
>
>And another theme is that some notes or letters are discarded...
>I expect to find 4 letters or other pages in the old notes about a
>surgical episode or medical admission. I expect to throw out three
>of them, perhaps extracting a datum from one to add to the surviving
>sheet.
>
> An aggressive programme of stripping out duplicated
>material
>and whitespace from paper notes,
>and putting results onto electronic storage is keeping the
>shelf-length nearly constant,
As in life generally, some people are hoarders and some are chuckers
out. Personally I am a hoarder. You never know when a letter or
consultation note you thought was irrelevant will later become
important.
I had a briefly disturbing experience with a pregnant woman who tested
non immune to Rubella. She angrily pointed out that we had reassured
her she was immune when she was tested some years earlier. When I
looked in the notes there was a handwritten note saying she was
immune, but the original lab report had been weeded and discarded (not
by us but by another practice who she had been with in between). She
alleged we had been mistaken and hinted at further action to come.
Fortunately, the lab still had a copy of the result and were able to
confirm that she had been immune previously. If they hadn't kept a
copy, we might have been in trouble. This story also illustrates
another problem intrinsic to GP paper records, namely that we rely on
the pt's next GP to preserve the notes that might save us from a
negligence charge. Ironically, current GP computer systems keep data
on ex patients indefinitely, even though they can't copy them to the
new GP.
Of course there is a problem with bulging paper folders, but surely
the great beauty of electronic storage is its ability to swallow vast
quantities of data effortlessly - e.g. just displaying headings with
successive layers of detail that you can click your way to, hidden
under the surface. There really shouldn't be any need to discard
anything.
David
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Dr David Evans
Cardiff
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