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Implementation of patient-centered medical records for short term mission trips in rural Haiti

Nabil Othman

1

, Francis Tinney

1

, Chih Chuang, M.D.

1

1

Wayne State University School of Medicine

World Health Student

Organization

Background

The World Health Student Organization (WHSO) of the Wayne

State University School of Medicine (WSU-SOM) is committed to providing free health care to underserved areas around the world, utilizing service-learning in global health education and to raise global health awareness. In February and March of 2014 the

WHSO sent two teams consisting of medical students and physicians to Morne, Haiti; a rural, mountainous region near the capital of Port-au-Prince.

In rural regions of Haiti, few citizens have access to healthcare.

Much of the healthcare is carried out by mission trips, which may or may not communicate with one another. Providers from one group may be unaware of the medications prescribed by previous groups, a problem exacerbated by lack of medical records. The purpose of this study is to describe a medical records system that was implemented across two short-term medical mission trips to

Morne which facilitated follow up care across a wide spectrum of medical disorders.

The Record System

The record system consisted of a booklet, created by our host organization Rays of Hope and distributed by the WHSO, with the following information:

1. Patient name

2. Vital sign measurements: height, weight, temperature, pulse and blood pressure

3. Medical diagnoses

4. Medication/therapies administered

In February, the booklet was given to patients after their discharge from the clinic. Those designated as follow up patients were encouraged to return when the second team arrived in March.

Patient Diagnoses

All Patients

Anemia

GERD

Parasites

Headache

HTN

URI

Vag Infection

Allergies

Tinea Capitis

Back Pain

Abd Pain

UTI

Scabies

32

28

Fungal infection 20

Pneumonia 18

Cough

Dry eyes

18

16

43

39

33

32

123

113

86

57

52

50

48

Dysmenorrhea 16

Generalized Pain 15

Ear infection

Pregnancy

15

14

Impetigo

Knee Pain

14

12

Constipation 12

Bacterial Vaginosis 11

Tinea Corporis 11

Asthma 10

Conditions with n>10.

Represents 75.6% of total diagnoses

Follow Up Patients

HTN 52

GERD 25

Fungal Infection 18

Allergy 13

Bacterial Infection 10

Asthma 9

Back Pain

Headache

8

7

Osteoarthritis 7

Generalized Pain 7

Diabetes Mellitus-

Type 2

Dry Eyes

6

6

Knee Pain

UTI

COPD

Gastritis

Hernia

Insect bite

4

4

6

5

4

4

Parasitic Infection 4

Sciatica 4

3 Catarcts

Dilated

Cardiomyopathy

Dry Skin

3

3

Dysmenorrhea

Impetigo

Joint Pain

3

3

3

Conditions with n>3.

Represents 83.7% of total follow up diagnoses

Different Patient Profiles

The average follow up patient had a different diagnosis than the average clinic patient. Follow up patients were chosen based on their clinical diagnoses: those who suffered from chronic conditions that require monitoring, such as diabetes and hypertension, were more likely to be chosen as follow up patients. Overall hypertension was the most common disease among follow up patients, where as in all clinic patients anemia, GERD, parasitic infection and headaches were more common. Of all clinic patients

4.2% were diagnosed with HTN, whereas that percentage increases to 23.5% in follow up patients.

RESULTS

• 107 total follow up patients

• 13 followed up, confirmed by name on intake form

• 9 of 13 patients had high blood pressure as primary diagnosis.

• 8 of 9 presented with lower blood pressure

• Average blood pressure drop was 25.4 (12.1) mmHg

• March mission trip carried out a survey of clinic patients: 95% of those surveyed (n=40) supported this new record system

Follow Up Patients

Hypertension

Back Pain

Ascites

CONCLUSIONS

1.

This pilot medical record book showed utility as a system to track the blood pressures of hypertensive patients.

2.

Medical record booklets keep health records in the hands of the patient population, so any medical mission trip has access to them while treating patients.

3.

The low follow up rate could be explained by human error: names could be recorded incorrectly, resulting in an artificially deflated follow up rate. The actual rate is likely higher than reported. Tracking patients by name is likely to be unreliable.

4.

It is a potentially effective way to facilitate follow up care for short term medical mission trips .

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