Patients' thoughts on patient-retained medical records

Abstract

Background: Patient-retained cards and, later, patient-retained booklets were introduced in an effort to improve continuity of care in a primary care setting at Tzaneen Clinic in the Greater Tzaneen Municipality of Limpopo Province, South Africa. Previously, the only continuity was maintained through a clinic-retained patient register, referral letters or information the patients provided themselves. The Patient-Retained Booklet of Lesotho provided motivation for this project.

Methods: A qualitative study was conducted using focus group discussions to explore the patients' thoughts on retaining their own records. In the transcribed interviews, themes were identified through the cut-and-paste method and the results where interpreted and compared with currently available literature.

Results: The participants thought patient-retained records were helpful. They felt that the records function as ‘medical identification' and could be used in the case of an emergency, that they provide important background information about the patient, and that they enable continuation of care at other facilities. Retaining the documents was also thought to motivate the patients to act on the advice given, and the records also served as a reminder to take their medication and about the dates of follow-up visits. It also was thought to personify the clinician-patient relationship.

Conclusion:The process of exploring patients' perceptions can be empowering. The patient-retained records gave the patients an opportunity to participate in their own health. It is a simple tool to improve quality in primary care by improving continuity of care and providing a helpful tool for future behavioural change. The recommendations that arose from this study are that the use of the patient-retained medical health record booklet should be continued and its use should be encouraged throughout the district; staff should be motivated to use it and to standardise the information that is recorded; and health planners should be motivated to implement a standardised patient-retained record booklet.

SA Fam Pract 2004;46(7): 30-33