Why record keeping is important

Dr Arpana Baldota

A systematic clinical record is quite a rarity in private medical practice. We find many medical practitioners who do not maintain records except the prescription and charges. Homoeopathic practice demands all attention to the details that enable individualisation.

A well maintained clinical record leads to the development of a sound clinical acumen,furnishes the best possible material for clinical teaching, research etc. and provides a reliable evidence of ones integrity and efficiency.
Record: It is essentially a written document of great significance depicting the patient as a whole and his symptomatology alongwith the treatment given.
Advantages and Usefulness of Record Keeping:
  1. Proper Assessment of the case: It plays a significant role specially in chronic diseases where there is a complex, vitiated picture. Without it a physician is not able to assess whether the patient has predominance of syphilitic, sycotic or psoric background. Therefore a proper record helps in the assessment of the disease.
  2. Selection of Second Prescription: After the first visit when the patient next comes to the physician the prescription has to be repeated, changed or potency to be altered depending on the case. For this purpose the case record has to be referred.
  3. Follow-up of Cases: In chronic diseases ,the patient has to take the treatment for a long period , which involves constant follow-up of the case. Therefore record keeping helps in maintaining follow-ups of the case.
  4. Judgement of the Action of Remedy: When patient is given some medicine, some change in symptomatology is expected. Eg – new symptoms appear, old symptoms reappear, disappearance of new symptoms etc. These all indicate the action of the medicine. This can be better analysed if we have an accurate clinical record.
  5. For proving the superiority of the system: There are different systems of medicine in the field of diseases with a run of competition everywhere. Therefore if a physician cures some incurable or a rare strange disease then the case record can be a documentary piece of evidance to prove the superiority of the system rather than making false claims.
  6.  As Reference: Some patients are not regular in their treatment or some patients get cured of one disease and come back to the physician for some other disease after a long time. In any of the circumstances if the case record is maintained properly then it can help the physician to tackle the new problem smoothly.
  7.  In legal procedures: There are few patients who make false complaints against the attending physician. In such cases the doctor may be sued legally. Here comes the protection by a well maintained record, as a documentary evidence in favour of the physician.
  8. Addition of fresh symptoms: As the  patient comes regularly to clinic, he always give new symptoms, or a change in the previous symptoms which can be added if doctor has maintained a record.
  9. Findings of Examination and Lab investigation: Clinical diagnosis is advancing with the introduction of new techniques for examination of the patient and lab. investigation.These findings can be accomodated from time to time if a case record has been maintained.
  10. For Clinical teachings: A well maintained case record can efficiently serve in the clinical teachings if some good cases have been elicited and recorded properly in details with follow-ups , mode &  line of treatment alongwith any change in symptomatology.
  11. Reflects the skill of the Physician: It is a reliable evidence of the integrity and efficiency of the doctor, his quality of dedication and thoroughness.
  12. For Research Purpose: If it is a well preserved document with all preserved document with all possible details it is very useful for research & further progress of the system.
  13.  Miscellaneous: Although a clinical record has multiple purposes but above all we say that it helps in arriving at a simillimum after making complete analysis & synthesis of the case, thus fulfilling the mission of a good physician.

Dr. Arpana Baldota
Associate Professor, Repertory
LSPEF’S Lokmanya Hom. Medical College
Email : drarpanabaldota@gmail.com

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