Today I would like to address an important subject and that is the importance of good record keeping.
More often than not it seems to be the little things in life that makes a big difference. Taking a comprehensive medical history, making proper notes and keeping these notes for an extended period of time, is of utmost importance!
I started of my career as a state dentist in prison services. One of the rules that I’ve instituted was the keeping of detailed dental records including dental x-rays of each prisoner. In fact each new prisoner had to visit the dental clinic as part of the admission routines.
During the first visit I would create a detailed chart of the prisoner’s dentition including the position of each filling, missing teeth and so forth.
Now, many years after I have moved on to further studies, a male prisoner was released, and he visited one of his old girlfriends. Unfortunately she didn’t want to have anything to do with him, and a fight ensued ending in this woman’s death.
Now this male prisoner fled into remote mountains and wasn’t found despite an extensive police man-hunt. About 18 months later a farmer came across skeletal human remains and informed the police, but there was no way to identify these remains, until the investigating officer and the state pathologist visited the prison’s dental clinic.
To make a long story short, a forensic dentist easily identified this skeleton as that of the missing prisoner using the dental records that I had created of this prisoner some years previously. A case successfully solved and that only because someone was diligent with keeping proper records!
Diligence in this area of medicine will avoid numerous complications, life threatening emergencies and will avoid many medico-legal incidents.
Project 0 in The Apprentice Doctor Foundation Course deals with how to take a proper medical history and keeping proper patient records. Don’t skip this project as it is indeed one of the most important projects in the course!
Finally, welcome to all the new Apprentice Doctors who visited The Apprentice Doctor booth at the Orlando Florida FPEA conference recently!
Committed to your success, and looking forward to hearing from you soon!
|Dr. Anton Scheepers, BChD, MDent, FFD(SA), MFOS, President of The Apprentice Corporation