Importance of Old Records



Glaucoma is a disease of a lifetime.  When meeting a patient for the first time, it is impossible to know their exact diagnosis and status.  It is like reading a murder mystery.  If you start on chapter 7, then you will never be able to solve the crime.  The same can be said for glaucoma.

We cannot stress enough the importance of old records.  We just do not take the word of the previous doctor.  I cannot count the number of times after reviewing the old records that the patient did not even have glaucoma and we were able to actually stop treatments, or the number of times the records clued us into the fact that the patient’s glaucoma was not controlled and we needed to advance treatment.

We at the Glaucoma Clinic never mind reviewing a chart to really make the exact diagnosis, treatment goal, and treatment plan for each individual.  Glaucoma is different in each individual, and without all the information, we just cannot tell whether someone is controlled or not.

Unfortunately, I have heard other glaucoma specialists tell me that it is just too time consuming to review a chart.  Although it takes time, the added information really benefits the patient.  Personally, I do not know how any doctor would not want to review the charts.  However, I guess I am old-fashioned, but I still think it is the best for the patient.  It does concern me that with the new electronic medical records it is not uncommon for the patient’s handwritten charts to be filed away in storage with difficulties to get access to.  Believe it or not, the companies even suggest that the records are not copied into the computer, but instead just stored away.  It may be even worthwhile for all patients to get a copy of their old handwritten records just to be sure that they are available if the information is ever needed rather than having those records stored away and destroyed.

Continuity of care is such an important factor here.  Having the old records allow us to make the best decisions for the patients having seen what has already transpired in the past.  It will only help us in the future.

Since we work in a town where patients are snowbirds, we always keep in constant communication with the patients’ northern doctors so that a testing and treatment plan can be arranged so that the expense and waste of time of duplicate testing can be avoided.

Similarly, we feel it is important in the snowbird population where two doctors are involved in one case that one doctor truly be the primary doctor and the other doctor assists while the patient is away.  We never want ambiguity or confusion regarding the exact treatment plan setup by the main doctor and the patient.  Being in Florida for 20 to 30 years, we are accustomed to taking on either role.  This is just another way to improve continuity of care, which in the long run is in the best interest of both the patient and the doctors.

Records, records, records, and communication make for a better outcome for both the patients and the doctors.

Stephen M. Wahl, M.D.