THE AUTHOR (Eric McAllister, the original author of this software application) was educated initially as a physicist in Nova Scotia, then as a biophysicist and computer modeler in the UK. After returning to Canada to teach and continue clinical research for several years, he completed medical qualification and began clinical practice first in British Columbia, then in California. Several years later, having adjusted to practice and seeking to further apply his research experience, he began a new career in clinical drug development (enhanced by his applied mathematics and computer background). Later, transitioning back and forth between industry and solo medical practice (including clinical studies in his own medical offices), a side interest of applying modern technology in his practice was a natural outcome.
CHARTSandNOTES is a labor of love that arose because of the many frustrations in general practice medicine — trying desperately to remember needed details of the case when out of the office; or important details of a drug about to be prescribed on the phone; or what lab tests are most appropriate to confirm a diagnosis; or even what ICD code corresponds to a diagnosis. Fortunately, personal computers were becoming both useful and affordable, as well as an engrossing hobby. What better focus for experimentation, then, than building a database application that would help me in my own practice?
Having begun practice in the days of scribbled paper notes, my standard procedure for a patient visit consisted of a quick review of the latest entries in the chart; then a face-to-face history & physical to confirm a course of action (taking extremely brief notes on a scrap of paper when necessary); then return to my desk to make some chart notes, and send any prescriptions and requisitions via my staff to deliver on the patient’s way out.
This procedure did allow for a gradual trial of my programming efforts. It soon became clear that a database page view made for a quick refresh of memory regarding the case before me. Also, every time something was lacking, I could steal time between patients to alter the program’s code enough to initiate a small improvement. Over the course of years, I found more ways to make practice more efficient: I could use templates for prescription and test requisitions, and summarize lab results on a single overview page for tracking. I could even graph weight and blood-pressure changes over time, instantly, and present the printout to the patient to reinforce compliance with a regimen. As storage media improved, I could take all my records home on a disk, and read them on a home PC (greatly diminishing fear of phone calls).
Hence, CHARTSandNOTES was born and reared. Now, with portable laptops and cloud storage, its advantages are even more valuable to me. I think it is an undertaking worth making available to the world at large. Despite large-scale efforts in developed countries to force uniformity on medical record-keeping, there will always be some who resist, often for excellent reasons. But in areas not yet undergoing such regimentation, I hope medical practice can be improved for doctor and patient alike, with very little cost and effort.
CHARTSandNOTES is still entirely in English, and I am not one who should attempt translations. However, translations should be relatively easy, particularly if the common SOAP (subjective, objective, assessment, and plan) format of charting is in use. If you see an opening, please have a go at it, with my blessing. Since all the actual medical entries and notes can be in any language using our alphabet, only the headings and instructions should need changing.
CHARTSandNOTES was developed in the United States (albeit by a dual-citizenship Canadian), so legal liability has always been a factor to consider. Conventional medical records consisted of paper charts in a locked office, retrieved from the files when needed by a practitioner. My continuing belief is that the signed paper record remains the best evidence for a court of law. Therefore, my approach with CHARTSandNOTES is this: every encounter with a patient results in a printed page that is immediately signed and place in the chart for filing. That paper chart is the legal record. The electronic record, useful as it is, is secondary. Of course it must be private and secure, and preferably encrypted if possible; but the paper chart trumps all.
A word about NOTES. This aspect of the software has been of immense use to me, and I think it may have the greatest potential for further development. Every time an important point to remember crops up, I summarize it in the appropriate section of CHARTSandNOTES so it is always available for future instant reference. Those notes can be any length, can be edited any time, and can even consist of cut-and-paste segments. They can refer to diagnoses, drugs, tests, or imaging. They start off as the personal notes of the owner. However, it would be possible for third parties to prepare notes as a service, too, should that be of interest to practitioners. (Of course, accepting third-party notes implies that one believes them — caveat emptor!).
With respect to conveying information: since any part of the record can be copied for pasting elsewhere, letters to consultants summarizing the reason for the consultation can be equally easy and informative. The nature of CHARTSandNOTES is such that sending the entire electronic chart (printed or electronically) would not add much, since the latest page contains all the ongoing diagnoses and treatments, and the initial identity page has all the background information available — so only 2 or 3 pages need be sent in order to provide a pretty complete summary of the patient’s medical course.
If you have read this far, you may be considering giving the software a try. I hope you do. It does not require any jolting changes in routine, if you are already using paper charts: just use CHARTSandNOTES for a patient or two and print those pages for the chart. In most cases, your staff will love you for it, since every written note will be perfectly legible! Over time, your charts will gradually change until, in a year or two, most will be printed and the remaining hand-written ones will become amusing reminders of the old days.
So — if you do become a user, please consider giving us your comments and advice. In fact, if you make changes to the software that seem to work for you, we’d all like to know. Everyone is at liberty to do so, and there is probably no single form that suits everyone perfectly.
Back to Home Page