Patient datasheets and generic evaluation sheets: tools for improving patient care, patient satisfaction, and chart documentation while decreasing physician frustrations.
A medical record system that utilizes a patient datasheet and pretyped generic patient evaluation sheets is described. When completed, the patient datasheet facilitates quick access to all of the pertinent patient medical information, improves transmission of instructions to the patient, simplifies record-keeping of patient visits, prevents the rewriting of repetitive information (such as a long list of medications and dosages and instructions after each visit), facilitates the tracing of the patient medication history, and improves communication with the patient and with other physicians. The "generic evaluation sheets" have a near-complete medical history and physical examination already typed with areas where information can be easily added or deleted and provides a place for the patient assessment and medical treatment plan. This approach to outpatient medical record-keeping not only results in the ready availability of patient medical information, thus decreasing some of the frustrations of patient care, but also markedly improves patient care documentation while facilitating referral letters and in-hospital patient records.
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University Heart Center, University of Arizona College of Medicine, Tucson 85724, USA.
D003142:Communication; D004282:Documentation; D006801:Humans; D008499:Medical Records; D016347:Medical Records Systems, Computerized; D017060:Patient Satisfaction