Medical Records: A Real-Life Patient's Story

The Patient’s Journey

This is a real patient’s story. I have permission to use the story to explore how information is a key part of a patient’s journey. This one begins in an office: Patient A goes to the washroom, and discovers blood in the basin after a bowel movement.

Patient A go to see colleague B, who happens to be a nurse, explains the problem and seeks advice. Whilst B is reassuring A, A loses consciousness. Fortunately B is a big guy who is able to lower A to the floor. A is unconscious for five minutes and comes around to hear colleague B on the phone to call an ambulance with some urgency. First aid support arrives followed in a short time by paramedics. The paramedics get a drip in and ask questions to check the patient’s status. By now there is blood on the carpet.

The patient is placed in a chair because the paramedics can’t get a stretcher up to the second floor where A has collapsed.

A is removed to hospital by ambulance where access to the emergency room is delayed due to a fire alarm. Once inside, A is examined by a nurse and then by a doctor. Blood samples are taken. A is placed on a saline drip to replace lost fluids. A medical history is taken from the patient including details of current medications and allergies. From here, after 40 minutes in the emergency department, A is removed to an assessment ward. On the way, the emergency room nurse tells A that they are “nil by mouth”. On arrival, there is no bed for A, who waits an hour to be assigned to a bed. Once placed in a bed, A is re-examined, and another medical history is taken from the patient including details of current medications and allergies. The blood tests have been sent to the lab, but unfortunately, the computer which makes them available across the hospital is not working correctly and they cannot be accessed. The conclusion is that overnight observation is required, and A is moved to a regular ward.

Once in the ward, A is asked if they want to order some meals for tomorrow, but A’s reply is that he or she doesn’t know if it’s allowed. The menu is brought and removed twice during the evening. At lights out, A is offered a hot drink and again questions its wisdom but the staff member is able to check and re-assure A that this is OK.

Next morning, A is relieved that all bleeding has stopped and that he or she feel relatively well with no pain. A is visited by the doctor who takes another medical history before deciding that an internal camera examination is required and A is discharged awaiting an outpatient appointment. Five days later, at a follow up visit in primary care, discharge details have not reached the primary care physician.

The Information Perspective

A’s journey highlights a number of information and IT issues. The medical history that sought by clinicians at least three times, is available. It exists in primary care. This is likely to be much more accurate than the recollection of a patient who is, by definition, dazed and confused. In particular, details of existing medications and allergies are available, and this is the major patient safety issue. Incorrect or incomplete information from a confused patient could lead to an adverse event.

Some key information is only passed on informally and subject to some confusion, e.g .the nil by mouth. Accurate information on bed availability is often a problem in hospitals and led to delays in full assessment in this case which was an inconvenience, but could have had more serious consequences. The use of paper and the mail to transmit discharge details meant follow up care decisions would have been taken on incomplete data, had A not taken the paper copy to the primary care appointment.

At the same time, those who believe that IT is the answer should note that dependency on IT requires a robust system, and this case the blood analysis results were unavailable.

Further Reading

Gillies AC (2006) The Clinicians Guide for Surviving IT, Radcliffe Publishing, Abingdon.