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Thai Medical Records vs. US Medical Records - PART II |
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Written by Administrator
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Monday, 17 November 2008 |
So how do Thai and US allergists compare in terms of their abilities to write medical records?
I believe that to some extent writing medical records requires the same skill sets as writing computer software. As a programmer, I write concise and efficient code. I also have to make sure my code is "comprehendable" (I know, I know, it's not a proper word) and "maintainable". I won't be working on the same program forever. Sooner or later someone else will come on board and take over my work.
Writing high quality code means that the new guy does not have to spend days or weeks or even months trying to decipher what the code is doing, why it was implemented that way, etc. I've seen many times in my career that a large chunk of code has to be thrown away because it's next to impossible to maintain it. The sad truth is that most computer software are written in a way that is not possible to maintain.
What does that have to do with medical records ?
Poorly written medical records mean that no other doctors will be able to easily review your medical history. Sometimes a problem, whether it's a software bug or an illness, lies in the history.
I now present you with two sets of records. One is from the famed Bumrunrad Hospital. The second one is from large medical clinic in SF bay area.
Here is my daughter's medical record which was written by Dr. Wittawa Asawavichianginda, an allergist, at Bumrungrad hospital. My major concern is that why they put "Cataract" as her Chief Complaint! my daughter never had a cataract. In fact, she never had any problem with her eyes. Was it a clerical error ? I don't know. But it's not good to have such a gross error on a medical record. (It's as if a programmer releases an application that upon being launched crashes your entire system.) The reason we brought her to be seen by an allergist was that she had rashes and eczema. Dr. Wittawa ordered some tests and confirmed that she's allergic to a lot of food. The record itself is beyond my abilities to fathom as it's so cryptic, well at least to me.
Let's take a look at the medical records from a visit to an allergist in the US.
And the second page.
This is a "comprehendable" and "maintainable" record. Any doctors, as long as they read English, would understand right away the conditions of my daughter's allergy symptoms. If these were computer code, I would never hire the person who wrote the first document.
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