| Ch 12 | Page 8 / 13 | |
| Multidiscliplinary approach |
Shared medical record | |
The extensive sharing of information is a preliminary necessity for good communication between carers. The best method is via a shared unique medical record, to which every carer has access and can add his/her contribution.
Such shared medical records are perfectly in accordance with the confidentiality duty that carers have sworn in the best interest of their patients. Sharing a medical record does not imply abandoning professional secrecy, although particular caution should be taken in order to preserve the patient’s intimacy.
A common language is necessary for each of treatment step:
Clinical description,
Anatomical classification,
Internationally recognised pathological classification
Research for risk factors.
Drafting of rules for surgical operative reports
Precise description of lesions,
Precise description of excisions and reconstructions performed,
Precise descriptions of lesions left after surgery,
Duration of the surgical procedure,
Radical surgery procedures: margin studies, protection against surgical dissemination.
In the expression of physical and biological dose,
Precise description of fractionation and spreading
Precise description of irradiated volume and energy
Precise recording of side effects (immediate toxicity)
Precise recording of late toxicity (by late reviewing of medical records).
Good differentiation between prescribed and administered dosage,
Dose intensity, delays and reduced dosage,
Common expression of acute toxicities (WHO scales),
General status description (Karnofsky),
Recording of rare side effects,
Recording long term side effects (by regular patient follow-up and retrospective studies of old medical records).
Simple recording of information on social, professional and family life,
More detailed quality of life questionnaires.
Looking for complications,
Studying modes of relapse,
Proposing efficient treatment,
Establishing the appropriate rhythm of follow-up consultations
Specifying the appropriate follow-up examinations,
Taking other associated pathologies into account.
Total and specific survival
Disease free survival, modes of relapse.
The medical record is therefore the unique communication tool between physicians for the benefit of the patient.
Sharing information whilst respecting medical secrecy is the first scientific step for forming a cancer network around the patient.
Even if many technical problems still remain, computerising medical records will become mandatory within hospitals, thus avoiding repetitive superfluous tests and examinations.
It is the aim of the French health system to build such a computerised medical record which will be the patient’s propriety, of which the patient will have as much knowledge as he/she desires, and to which the patient will grant access to his/her physicians.
Another project involves the secure Internet access to medical records among all carers in a regional area, with the patient’s permission. With improved information, treatment should be facilitated and further adapted to each clinical situation.
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