Categories
Burnaby Division of Family Practice Medical Ethics patient-doctor relationship

Keys to a Better Hospital Stay

Illnesses and accidents are unpredictable and we can’t always predict when we may end up in a hospital. Here are some tips to prepare and how to maintain a sense of control in the mysterious world of the hospital.

PREPARING FOR YOUR HOSPITAL VISIT

  1. Always wear clean underwear but don’t count on it staying clean if you’re surprised by an accident.
  2. Don’t miss an opportunity to use a washroom.
  3. Remember to wash your hands!

 

WHAT TO PACK

Essential Medical Information

  1. Your Medical History A one-page summary should include: allergies, chronic conditions, past illnesses and surgery, and family medical history
  2. Your Medicationsdrug name, dose, directions

and reason for taking it

e.g. Brand name: Tylenol

Generic name: acetaminophen

Dose: 325 mg

Directions: one tablet twice daily

Reason: for knee pain

  1. Your Preferences: An Advance Directive is a statement of what kind of medical care you would want in the event that you are unable to make your own decisions.

What procedures do you want?

What procedures do you refuse?

Under what conditions?

Who do you choose to make decisions for you?

e.g. You may not wish to have CPR (chest compressions, assisted breathing, a tube down your throat, electric paddles on the chest) if you had an irreversible, terminal condition with no hope for a return to an acceptable quality of life (by your standards).

You may not wish to be kept alive on machines if you were in a persistent coma with no hope of recovery.

TIPS:

Always plan in advance.

Talk it over with your family and friends (to avoid difficult family conflicts).

Choose someone you trust to respect your wishes.

Inform your doctor.

Put it in writing.

For more information: google “My Voice”

Click to access MyVoice-AdvanceCarePlanningGuide.pdf

 

Comfort Items ear plugs, music, reading, word puzzles, eye mask for sleeping, toothbrush and paste, warm socks, non-slip slippers, a sweater

 

To Keep You Oriented a calendar,a quiet inexpensive clock

 

For Communication a pad of paper, pens, your glasses, hearing aid and teeth

 

What NOT to bring expensive jewelry, watches, electronics, wallets, purses, credit cards, your nicest clothes and shoes, and other prized possessions

 

Don’t bother with perfume or cologneYour neighbours may have allergies and respiratory problems

 

3 KEYS TO A BETTER HOSPITAL STAY

  1. Stay in control (and informed)

4 Things you need to know about every test, procedure and treatment

  1. The purpose or reason
  2. Common side effects or risks
  • Serious side effects or risks
  1. Alternatives (e.g. other treatments)
  2. Know your team
  3. Ask for each person’s name and role

(e.g. nurse, respiratory technician, dietician, physiotherapist, occupational therapist)

or specialty (e.g. family physician, hospitalist, surgeon, internist)

  1. Ask who is your attending or most responsible physician
  2. Set up a channel of communication

Prepare your list of questions.

Find out when your attending doctor will visit.

Key questions: What is the plan? The working diagnosis? The schedule of tests or procedures?

The results of tests? The expected day of discharge?

 

This information could be shared on a WHITE BOARD in your room or a large pad of paper at your bedside.

 

Make sure your family doctor knows you are in hospital and that hospital reports are sent to the office He or she can provide important medical information to your hospital care team

Preparing for Your Hospital Stay https://www.youtube.com/watch?v=cR0qs4lY19Q&feature=youtu.be&list=PLAWTWe0JNCdHrKBo0F03pjLdDeENFrctX

Three Keys to Improving Your Hospital Stay https://www.youtube.com/watch?v=X1t3qDTQ48I&index=2&list=PLAWTWe0JNCdHrKBo0F03pjLdDeENFrctX

The Lonely Patient’s Guide to Hospital Land  https://www.youtube.com/watch?v=Uu08JBbNKe8&list=PLAWTWe0JNCdHrKBo0F03pjLdDeENFrctX&index=3

 

Dr. Davidicus Wong is a physician in Vancouver, British Columbia, Canada.

                

Categories
Caregiving Love Medical Ethics patient-doctor relationship Positive Potential Purpose Relationships Your Calling Your Goals

Find your inspiration!

DSC04776

To make the most of this life, we must make the most of each day.

What inspires you to rise out of bed each morning, do what needs to be done, pursue your goals and give the extra effort that makes a difference? What gets you through the in between times with a mountain range of challenges between you and your destination?

From an early age, I was hooked on reading. By grade 6, I had finished reading the World Book Encyclopedia and spent hours each week at the McGill Branch Public Library in North Burnaby. Like my mom, each week, I would borrow my limit of books.

I was inspired by Norman Vincent Peale’s The Power of Positive Thinking, Dale Carnegie’s How to Win Friends and Influence people and James Allen’s As a Man Thinketh. I learned much more from countless books, and my eyes opened to an expanding horizon of possibilities.

So enriched and moved by the writing of others, I imagined how wonderful it would be to help and inspire others with my own words some day.

For ten days in grade 6, I had a flare-up of rheumatoid arthritis with rashes, fevers and painful joints. On Burnaby Hospital’s pediatric ward, I was cared for by my doctors and nurses who weren’t treating a disease but rather me as a whole person. I trusted them to do their best for me, and it was then that I decided to be a physician – to give forward the care that I had been given and to care for others when they are most in need.

An inspiration can get us started on a path, but what keeps us going?

We can be most inspired by those we serve. When I became a parent, the awesome responsibility of caring for a helpless baby, loving unconditionally and nurturing each of my children to their greatest potential was the greatest of callings.

I had to rise to this responsibility and strive to be my best to give my best. My children have made me a better person.

As a physician, I developed my golden rule of medicine: treat every patient with the same degree of care and consideration I would want for a best friend or family member. For any of my patients, I refer to the same colleagues and order the same tests in the same time frame that I would want for those in my personal life.

The needs of my patients have inspired me to be a better physician. I am inspired and supported by a few of my colleagues, including my classmate, Dr. John Law, who like me, commit to continuous quality improvement in their clinical skills and looking outside of the box, learn advanced techniques to meet the needs of our patients.

The most inspiring physicians learn from one another and from their patients.

In your personal life, whom do you serve? Look both inside and out of your own home, community and workplace. If there is a need, can you rise to meet it?

Each day presents us with infinite opportunities to make a difference big or small – to lift up the hearts of a few people and to live a meaningful life.

Celebrate Inspiration Day from 10:30 am to 1 pm on Saturday, February 6th at Century House at 620 Eight Street in New Westminster. I’ll be there to enjoy the entertainment of the Century House Singers and Comedians and give the keynote presentation. Admission is $5. Call (604) 519-1066 for more information.

Davidicus Wong is a family physician and his Healthwise columns appear regularly in the Burnaby Now, Royal City Record, Richmond News and Vancouver Courier. For more on achieving your positive potential in health, see his website at www.davidicuswong.wordpress.com.

Categories
Burnaby Division of Family Practice Empowering Healthcare Happiness Healthy Living Medical Ethics patient-doctor relationship Preventive Health Screening Tests Self-care

Empowering Patients with Knowledge

The Future of Family Practice.jpg

When you think about the work of your family physician, you probably envision the one-on-one care he or she gives to each individual patient. It may be a clinic, hospital or – more rarely – home visit.

That still remains the priority of virtually every family physician: the wellbeing of every patient in his or her practice, but you might be surprised to hear that the circle of care is expanding. More physicians in our community care about the health of the entire community.

The Burnaby Division of Family Practice is a non-profit organization founded in 2011 and funded by the General Practices Services Committee. Its members are the family physicians who serve our community.

With the other founding board members, I wrote our organization’s vision and mission statements. Our vision for the Burnaby community: patients and physicians achieving health and happiness. Our mission: to engage, support and mobilize family physicians in co-creating a network that will support the wellbeing of all members of the Burnaby community.

Although I’ve recently stepped down from the board of directors, I continue to lead the Burnaby Division’s Empowering Patients public health education program. Recognizing that the public receives confusing and often incorrect medical information from the media, we sought to provide unbiased information

Our vision is that by raising general health literacy (public knowledge about healthy living and how best to use the healthcare system), we can improve the health of our community. We may be able to reduce the burden of chronic disease in the future.

Since we started the public education program in October 2014, we’ve delivered 11 public presentations in our community’s libraries, schools and community centres. The topics have included healthy eating, healthy relationships, emotional wellness, healthy physical activity, patient-doctor communication, making the most of your hospital stay, medical ethics and common chronic health conditions, such as diabetes.

Summaries of each of these presentations is available on the Burnaby Division of Family Practice’s website https://www.divisionsbc.ca/burnaby/empoweringpatients. There you will also find the dates for future talks in the series and links to our videos on emotional wellbeing, making the most of a hospital stay and important symptoms for which you should seek medical care.

I’ll be speaking on “Making Sense of Symptoms and Screening Tests” at 7 pm on Tuesday, December 8th at the McGill Library on 4595 Albert Street in North Burnaby. Growing up in North Burnaby, this was my “home library” close to the Eileen Dailly Pool and the Confederation Community Centre. I’ll go over the “review of systems”, the questions that physicians include in a complete physical examination. Because no one gets routine physicals anymore, most people are never asked these questions about the symptoms that may indicate important medical conditions.

When patients receive episodic care at drop-in clinics, they may not be aware of what tests they should be having and when. For this reason, I’ll also review the key screening tests that are recommended at different ages.

To register for this free talk, please contact the McGill library at (604) 299-8955 or http://www.bpl.bc.ca/events

Categories
Burnaby Division of Family Practice Empowering Healthcare Medical Ethics

Why Ethics Matters to You

A  Primitive Advance Medical Directive (before surgery)
A Primitive Advance Medical Directive (before surgery)

Do you believe that medical ethics is an area of philosophy that doesn’t apply to you?

Many share that misconception. The principles of bioethics – autonomy, confidentiality, beneficence and non-maleficence – certainly sound like high level philosophical concepts. No wonder people assume that they’re not relevant to their everyday lives.

In reality, ethics is at the core of your relationship with doctors and other healthcare providers. Although we seek to help our patients (the principle of beneficence), this must be balanced with the risk of doing harm. Every treatment, medication and test carries potential risks, including side effects and complications. For this reason, the first rule of medicine is to do no harm (non-maleficence).

Tests and treatments, including medications and procedures are merely the tools of medicine; ethics guides us in their use.

In the practice of medicine, we have evidence-based protocols and guidelines on the best treatment of specific medical conditions, such as an acute stroke or heart attack. They are continually being updated based on clinical research. However, the treatment that individual patients would choose for themselves may not be what the guidelines recommend.

In healthcare, we do not treat medical conditions in isolation; we treat the whole person in the context of a unique life. Individual autonomy (the ability to make one’s own choices) is a fundamental guiding principle.

For example, if a previously capable adult was unconscious after suffering life-threatening blood loss in an automobile accident, the emergency doctor may recommend a blood transfusion to save his life. However, if that patient when capable left clear written instructions that he would not accept a blood transfusion under any circumstances, his wishes would be respected by the physician even if family members want him to receive the blood.

During the time that Burnaby Hospital had its own Ethical Resources Committee, I was the chair for 17 years; in my last 10 years in that role, I led a team providing ethics consultations at the request of families, patients and healthcare providers when they couldn’t agree on the best course of action.

Many of the patients we were asked to see were in the intensive care unit or in long-term care, where it wasn’t clear if life support such as machine-assisted breathing, feeding tubes and IV fluids would provide benefit to the patient. In all cases, the patients were unconscious or for other reasons no longer capable of understanding their situation, making medical decisions and communicating their preferences to the care team. In none of the cases had the patients put anything in writing in the past when they were capable of giving consent.

Family members would then have to make heart-wrenching decisions on behalf of the patient based on what they thought their loved one would want. Dilemmas arose when family members disagreed with one another or with members of the hospital care team.

Sometimes, it wasn’t clear which family member was the most appropriate decision maker on behalf of the unconscious or otherwise incapable patient.

If you were the patient, who would you choose to make decisions on your behalf? Would they respect your values and all that gives your life meaning?

Who has the right to see your medical records? Under what circumstances may you lose the right to make your own decisions? How do you make your wishes known in advance?

I will address these questions in upcoming columns and at 7 pm on Tuesday, April 7th at the Bonsor Recreation Complex. I’ll be speaking on a topic relevant to your care both in and out of the hospital, “What You Should Know About Medical Ethics.”

This free public talk is part of the Burnaby Division of Family Practice’s Empowering Patients education series For more information, call Leona Cullen at (604) 259-4450 or register online at lcullen@divisionsbc.ca.

Dr. Davidicus Wong is a family physician. For more information on the Burnaby Division of Family Practice’s public health education series, check our website at divisionsbc.ca/burnaby. davidicuswong.wordpress.com.

Categories
Burnaby Division of Family Practice Empowering Healthcare Healthy Living Medical Ethics

Are you prepared for a visit to the hospital?

Davidicus Wong's Black Bag

The odds are in favour you’ll one day find yourself in a hospital, and the older you get, the greater the odds that you will. You might as well pack your bag today because being a patient is a lot like taking a trip to a very foreign country.

If I were to write a guidebook for hospital patients, I’d call it “The Lonely Patient’s Guide to Hospitaland.”

The inhabitants dress differently – usually in greens and white coats, and it’s hard to tell who’s who.

Doctors wear nametags with their first and last names. Almost all the rest of the staff shows only first names. You however have to wear a wrist band with your full name, birth date, PHN and the name of some doctor you may not recall meeting.

If you have allergies, you earn an extra brightly coloured wristband, but don’t mistake this for an all-inclusive resort. The closest thing you’ll get to a massage might be a sponge bath.

In the summer time if your semiprivate room is too hot, you might hallucinate that you are in a sauna since you and the other guests are all nearly naked beneath your very thin hospital gowns.

And like the pool deck, you’ll see more than you wish of the scantily clad guest strolling by where gowns don’t quite cover up.

While you’ve heard that in some countries a five star resort is really four stars in quality, when you start complaining that the food is only two stars, doctors take this as a sign that you’re getting better or at least nearly normal and ready for discharge.

The inhabitants of Hospitaland speak a different language. Instead of “aloha”, we have other multipurpose, ill-defined words like “rounds.” When a doctor visits patients at the bedside, we call this doing rounds. When a bunch of doctors gather to talk about one patient, we call that department rounds. When doctors gather for group education, it’s called grand rounds. When doctors and nurses meet to talk about the patients on the ward, we call it team rounds. When I can’t find anyone to help me read a CT scan, all the radiologists are on brown rounds (that is a coffee break).

They also speak in CODE. Code Blue is a cardiac or respiratory arrest. Code Pink is a maternity emergency. Code White is a psychiatric emergency. Code Yellow is pee on the floor and a potential WorkSafe hazard. Every hospital has its own code.

The inhabitants have odd customs. Everyone who talks to you will write in a big binder with your name on it, but don’t dare try to look into that binder yourself. A stern and scary nurse will tell you that you are not allowed to do this without medical supervision – unless you care to fill out a bit of paperwork and wait (until you are discharged from the hospital). If you hadn’t been diagnosed with paranoia on admission, you might be before discharge (but don’t take my word for it. Just try to look in that binder).

On Friday, March 27th at 7 pm, I’ll be speaking on “How to Survive Your Hospital Stay” at the Confederation Community Centre at 4585 Albert Street in North Burnaby (near the McGill Public Library and Eileen Daily Pool). This free public talk is part of the Burnaby Division of Family Practice’s Empowering Patients education series. I’ll tell you everything you need to know to have the healthiest, least eventful hospital stay possible. For more information, call Leona Cullen at (604) 259-4450 or register online at lcullen@divisionsbc.ca. In my next column, I’ll tell you what to pack for your inevitable trip to Hospitaland.

Dr. Davidicus Wong is a family physician. For more information on the Burnaby Division of Family Practice’s public health education series, check our website at divisionsbc.ca/burnaby.  

Categories
Empowering Healthcare Medical Ethics patient-doctor relationship Positive Potential Preventive Health Screening Tests Self-care

Become empowered in your own healthcare

Photoshoot 2

At some time, we will each play the role of the patient.

In the 1991 film, The Doctor, William Hurt plays an arrogant physician who gets a taste of his own medicine when he is diagnosed with cancer. His experience from the patient’s perspective transforms his life and his practice.

My experience as a patient came early. As a child, I was diagnosed with rheumatoid arthritis, hospitalized for two weeks and had more blood tests than most of my patients.

But the personal experience of both acute and chronic illness and receiving care from good doctors and nurses has informed both my calling to the profession and my practice.

The Burnaby Division of Family Practice is the non-profit organization of the family physicians that serve the people of our community. In our ongoing public education program, that includes free public lectures and information on the organization’s website, we seek to empower all members of the community.

Through our organization, the family physicians’ care for the patients of their own practices has expanded to the care of our community. We seek to raise the level of health knowledge and healthy living to support the wellbeing of all.

Although we’ve thought of ourselves as the big providers of healthcare, 90% of your healthcare is self-care – what you do for your self. The best predictor of your future health are the habits you practice today.

We’ve been promoting the four foundations of self-care: healthy eating, physical activity, healthy relationships and emotional wellbeing. The next three public lectures focus on empowering patients in their interactions with healthcare providers.

On March 4th, I’ll be talking at the Bonsor Community Centre about preventive care and the early recognition of illness. We’ll review the important screening tests (what tests you need at different ages) that identify medical conditions before symptoms appear. We’ll also talk about symptoms that may indicate conditions for which you should seek medical attention.

Although you may do your best with healthy living and preventive care, you might still find yourself in the hospital as I did. It can be a very unsettling experience and at times you may feel a loss of control. On March 27th at Confederation Centre, I’ll provide useful information on making the most of your hospital stay and ensuring you have the best experience.

On April 7th at the Bonsor Community Centre, we’ll discuss what you should know about medical ethics, including how to ensure your wishes are respected, who has access to your medical records and how to make informed decisions about medical interventions.

In the patient-doctor relationship, the patient comes first. The role of your healthcare providers is to support you in both managing illness and achieving your goals. We envision the Empowering Patients education program will provide some of that support.

Dr. Davidicus Wong is a family physician. For more information on the Burnaby Division of Family Practice’s public health education series, check our website at divisionsbc.ca/burnaby.

Categories
Empowering Healthcare Medical Ethics patient-doctor relationship Uncategorized

Three keys to a better hospital stay

Prague Castle
What happens if you try to run in a hospital gown (Prague Castle)

If you’re admitted to a hospital, you may lose your sense of control over your own healthcare.

You’re expected to wear a gown instead of your own clothes. Many people pop into your room unannounced, and they write notes in a chart that you can’t see. You may be given medications but not know what they are for, and sometimes, you may not know who is making decisions for you.

Yet autonomy is a cornerstone of medical ethics. Capable patients must be sufficiently informed in order to make the best decisions for their own care.

When you visit a physician, nothing is done without your consent. After listening to your concerns, asking more questions and performing an examination, the physician will offer a working diagnosis and suggest some options for investigation or treatment.

In order to make informed decisions, you need four key pieces of information: (1) the purpose or reason for the treatment or investigation, (2) the common side effects or risks, (3) the serious, including life-threatening, side effects or risks, and (4) alternatives to the proposed treatment or investigation.

Here are three keys to improving your hospital experience.

  1. Stay in control. If you are capable of understanding your situation and treatment options, you should continue to make important decisions about your care in the hospital. Ask the four key questions for any proposed treatment or investigation.

Ideally, you should express your wishes before you find yourself in the hospital. Consider writing an advanced medical directive. If you become ill or incapacitated, what types of treatment would you want? If you were no longer capable of making your own decisions, whom would you entrust to make decisions on your behalf? Discussing these issues ahead of time will make things easier for your family and will make it more likely that your wishes will be respected.

  1. Know the team. There are so many people working in the hospital that many patients don’t know who is who. It doesn’t help that many health care workers wear surgical scrubs (or “greens”) and white lab coats.

What could be easier than getting up and changing from comfy pink sleeping pajamas to comfy green pajamas? If we all did this, no one would buy pajama jeans.

You could try to read the nametags, but if you’re not sure, don’t be shy. Ask for each person’s name and their role (i.e. nurse, respiratory technician, pharmacist, dietician or doctor). If it’s a doctor, what is their specialty (i.e. internal medicine, hospitalist or surgeon)?

Most importantly, you need to know who is the “attending physician” or “most responsible physician.” This is the physician who is directing your care throughout your hospital stay. It is possible that this might change from day to day which of course is less than ideal.

  1. Set up a channel of communication with your attending physician. Some hospitals have white boards in every patient’s room indicating the plan or schedule of tests or procedures, the results of tests and the expected length of the hospital stay.

If this isn’t the case, you should have a large pad of paper at your bedside so that this information could be written down for you. You should prepare your own list of questions for your doctor. Try to find out when that doctor is expected.

Like the traveller forcing himself to stay awake on the plane so he won’t miss his meal, patients dread falling asleep and missing the doctor during daily rounds.

I’m hoping you won’t find yourself or your loved ones in the hospital any time soon, but if you do, follow these three steps to maintain control of your care.

 

 

Preferences
Preferences
Preferences
Preferences
Preferences
§
1
2
3
4
5
6
7
8
9
0
=
Backspace
Tab
q
w
e
r
t
y
u
i
o
p
[
]
Return
capslock
a
s
d
f
g
h
j
k
l
;
\
shift
`
z
x
c
v
b
n
m
,
.
/
shift
English
alt
alt
Preferences
Categories
Empowering Healthcare Medical Ethics patient-doctor relationship

What you should know before you fill that prescription

 

 

Prescription by Davidicus Wong

 

It is a well-worn ritual.

 

Near the end of your medical visit, the doctor gives you a prescription. Traditionally, it is handwritten and because calligraphy isn’t a prerequisite for medical school, you may not be able to read it.

 

Most patients are like polite travellers in a foreign country. They may not understand everything that was said, but they’re willing to take a leap of faith and assume they got the gist of it.

 

That may be a big risk if you’re travelling close to the border of a hostile country or about to take a potentially dangerous drug.

 

An important principle in medical ethics is informed consent. In order to make a decision about what treatment – including medication – to take, you need sufficient information.

 

So what should you know before you fill that prescription?

 

There are five crucial areas of information summarized with my acronym, BRAIN: Benefits, Risks, Alternatives, Interactions and the Need for follow-up.

 

The first question you need to answer is, “What is this drug for?” (i.e. What are the intended BENEFITS?) That’s what your family will ask when you get home. So if you’re not sure, you should ask before you leave the doctor’s office.

 

It’s not unusual for a patient to come out of the hospital or a clinic with five or more medications but not know what each is supposed to do. Doctors don’t mind clarifying this. We don’t want you to be on any more medications than you need.

 

The second area of information you need to know are the RISKS of taking this medication. These are the potential side effects. You won’t get every single side effect listed in the pharmacy handout. Only a few lucky winners will hit the jackpot. Like most lottery players you may not get any at all. However, as doctors, we should tell you the common side effects and the serious side effects (even if they are rare).

 

For example, the common side effects of oral steroids, such as prednisone, are immune suppression, insomnia, osteoporosis, stomach irritation and ulcers. A rare but serious side effect is avascular necrosis of the femur that may require a hip replacement.

 

Many drugs cause nausea and changes in bowel movements. Most drugs – including herbal remedies – have the potential for allergic reactions.

 

The third question that should be answered is, “What are the ALTERNATIVES?” What are the risks of not treating this condition? Are there other medications – cheaper or more expensive, synthetic or natural? Would lifestyle changes (i.e. a better diet or more exercise) be sufficient?

 

The fourth important area of information you need is the potential for INTERACTIONS with food or other drugs. Grapefruit juice interacts with many medications. It can raise the blood levels of many cholesterol-lowering drugs and increase the risk for side effects. The blood thinner, warfarin has to be carefully dosed in order to be effective in preventing blood clots without increasing the risk of bleeding. Many medications interact with warfarin, including non-prescription acetaminophen (Tylenol) and vitamin K (present in many foods, including green leafy vegetables).

 

Finally, the fifth area of information you require is the NEED to follow up. If this is a short-term prescription – such as a course of antibiotics for an ear infection, should you return to the doctor if you’re not better? How long should you wait?

 

If the prescription is for a chronic condition, such as diabetes or high blood pressure, how often should you be monitored? When should you be rechecked?

 

Autonomy is a cornerstone of western medical ethics, but to make informed decisions about your health, you need this important information. If you’re not sure, ask these questions and pick your doctor’s BRAIN.

Categories
Medical Ethics patient-doctor relationship

What would you find in your medical records?

Exactly what is in your personal medical record – the paper file in your family doctor’s office or the electronic record in the clinic’s computer? What key information should you know by heart or at least have at your own fingertips?

With every medical visit, your doctor will create an entry either written in a paper chart or typed into an electronic record. In both cases, an entry must be dated and usually follows the standard SOAP format.

S stands for subjective: what you describe to the doctor. This includes the key details of the history of your symptoms, such as the type of pain you have been experiencing – its location, quality, intensity and duration, what makes it better and what makes it worse.

O stands for objective: the results of previous investigations and the findings on the physical examination. This includes what the doctor sees or measures, hears with the stethoscope and feels on palpation.

A stands for assessment: the diagnosis or multiple possible diagnoses we want to confirm or rule out.

P stands for plan: the investigations or treatment offered or recommended.

Doctors are required to write these clinical notes in such a way that it is clear what was found on examination, what the doctor was thinking and what was discussed with the patient. They should be written in such a way that another physician would be able to follow the doctor’s logic and know what the next steps would be.

Before I step into an examination room, I review the previous visit and any reports or test results that have come in since then. After each visit ends, I spend a few minutes completing the chart notes.

If there is time, I’ll complete the forms or write the letters required for more extensive investigations or referrals to specialists, but usually I’ll complete these at the end of the workday.

Also within your medical record are the results of investigations, including x-rays, scans and lab tests; admission, operative and discharge reports from hospitals; and the consultation letters from specialists. These are filed in specific sections in chronological order in both paper and electronic charts.

In every paper chart (usually the inside cover) and in every electronic record should be a summary of the key information from a patient’s medical history. This is the information you should know by heart in case you have to see another doctor in a different clinic or ER: drug allergies, current medications (their doses and directions), significant past illnesses and hospitalizations, current and chronic medical conditions (such as high blood pressure or diabetes), previous operations, significant medical procedures (including their dates) and your family history.

If you don’t have all this information, ask the staff at your family doctor’s office to help you fill in the blanks. However, be patient with them. Medical office assistants are the backbone of the clinic, working hard to support both patients and physicians, making appointments, organizing tests, arranging referrals, filing results and reports, and ensuring your records are secure.

Dr. Davidicus Wong is a family physician at the PrimeCare Medical Centre. His Healthwise column appears regularly in the Vancouver Courier, Royal City Record, Burnaby Now and Coquitlam Now. He is a regular Tuesday morning guest on Jill Krop’s AM/BC talk show on BC1 (channel 21 on Shaw). 

Categories
Medical Ethics patient-doctor relationship

Your Medical Records: What You Should Know

EMR

For a good part of my childhood, my mom would take me to almost monthly visits to my pediatrician who was treating my rheumatoid arthritis. She also accompanied me for more blood tests and x-rays than I have ever ordered on a child.

Though I’m sure I thanked my mother each time she took me out, I wish I could thank her again for all the concern I must have caused her. She would reassure me so I wouldn’t have to worry.

Curious about the results of all those tests, I requested my records after graduating and starting my own practice. Unfortunately, I learned that the pediatrician’s office had shredded my chart the month before.

In B.C., doctors are legally required to retain medical records for a minimum of 7 years after the patient is last seen or after the age of 19 (i.e. age 26) whichever is longer.

This will change on June 1st. The College of Physicians and Surgeons of B.C. has changed its requirements to reflect changes to the Limitations Act. After that date, doctors must retain medical records for a minimum of 16 years from the date last seen or the age of majority.

Adults sometimes think about their medical records as something that will always exist just as some young people may assume that what’s on the internet will always be there. But just as your old facebook and blog posts will not remain online forever, your old charts may be destroyed if sufficient time passes.

For those who have moved and haven’t found a new family doctor, your old records may be gone before you have a chance to transfer them.

Your medical records belong to the physician or the facility where you have been treated. They include consultants’ letters, surgical reports, lab results and other investigations in addition to the clinical notes of the physician.

Those clinical notes are generally written with the sometimes illegible shorthand and abbreviations of physicians. They aren’t really written to be read by a layperson. Rather they are meant to provide a summary of each patient-doctor encounter written such that another physician could clearly understand what was said (the history), what was found (on examination), what was suspected (the differential diagnosis) and what was planned (the treatment, investigation and the follow-up).

If you walked into your doctor’s office and asked for your chart, it wouldn’t immediately be handed to you. Reviewing records – particularly the clinical notes – requires assistance from someone with a medical background. For example, if you read “S.O.B.” in your chart you might feel insulted though the doctor was simply using the accepted abbreviation for shortness of breath.

Though you don’t own your medical records, you have a right to the information contained within them. You should be cautious when signing off the right to share your confidential information with a third party.

When you – or someone else such as a lawyer with your written permission – requests the copying or transfer of your records, the doctor’s office will charge a fee that is generally reasonable and proportionate to the time required to review the records and produce copies.

The main reason medical records are destroyed beyond the legal retention limit is the amount of space required by the traditional paper chart. I’ve had some patients whose charts filled three file folders.

The problem of space will eventually be resolved with the widespread adoption of electronic medical records.

Coming up: What key information should you have from your medical records? What privacy issues arise from electronic chart?

Dr. Davidicus Wong is a family physician at the PrimeCare Medical Centre.  He is a regular Tuesday morning guest on Jill Krop’s AM/BC talk show on BC1.