ROJoson 2013 Medical Clinic Patient Registry Form – Revision 1

ROJoson 2013 Medical Clinic Patient Registry Form – Revision 1

NOTE: With the feedback from Marylou, I revised the form that I presented on December 5, 2012.

Each private medical clinic and each privately practicing physician have their own unique registry forms for new patients to fill.

The forms will vary depending on the needs of the clinics and the physicians.  As of this writing (December 5, 2012), in the Philippines, I am not aware of any Department of Health regulatory requirements on what should be the contents in such a patient registry form.

My personal registry form has evolved since I started private practice in 1981.  It started with an index card that just asked for patient’s data on name, age, sex, address, and contact number.  The cards were filed in index-card boxes.  Then, over the years, I cannot recall when, a one-pager form came into use that asked for more personal data together with data on diagnosis and treatment done that I had to fill at the lower part of the data sheet.  This form served as the covering page of the medical records of my patients in my clinic.

I have changed the contents of the one-pager patient registry form over the years.  As far as I can recall, I have changed them at least 10x already as of 2010.  I have records of  formal reviews of my form in 2006, then 2008, then 2010 (at 2-year intervals).

In 2010, I started asking for cellphone numbers and email addresses of my patients.

Today, December 5, 2012, I decided to review the contents again.  I am revising them to include among other things, Facebook addresses of my patients, if they have.

Below shows the new one-pager patient registry form that I will start using in January 2013.



As I said above, I still have records of reviews in 2006, 2008 and 2010.

Here are some excerpts from the records on the objectives of reviewing and refinement procedures to be done which I like to share with my patients and colleagues:

Objectives of Reviewing:

  1. To professionalize management of my clinic records (patient records).
  2. To use the improved management procedure of clinic records as a strategy in clinic development.
  3. To develop a model of management of clinic records to share to physicians-to-be.

Procedures in Records Creation and Generation:

Form should be filled by patient or relative and assisted by my secretary to ensure legibility and accuracy (secretary should not hesitate to fill another form if needed).

  • In the Patients’ General Data, include email addresses of patients and relatives – to use them for health advisory and  part of clinic development.
  • Include types of patients – insurance or not.
  • Include specimen signatures of patients and relatives – to facilitate signatures on informed consents and advice sheets.
  • Use the form to inform patients and relatives of my specialty – part of clinic development.
  • Include Patient’s Declaration of Health Information -to protect me if patients kept essential information from me that result to complications in management.
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2 Responses to ROJoson 2013 Medical Clinic Patient Registry Form – Revision 1

  1. rojoson says:

    hi rey,

    here’s my 5-cents worth of input for you.

    you might want to consider providing a small space in your registry form to allow your patients to list all medications currently being taken when they fill up your form. you can update this, as needed, during follow up visits or future consults.

    i notice all doctors we have visited over the years always ask us for this piece of information when we’re already inside the consultation room. i feel that if the patient had been asked to list this in advance, it would allow the patient to be more thorough and not miss out on anything because he / she would still be in a semi-relaxed condition vs. being under heightened stress when already seated in front of the doctor. (this happens to some patients.) the value added to the physician is that it may, hopefully, save you some time since you don’t have to ask and list this down yourself anymore.

    by the way … on the subject matter re: keeping medical records in clearbooks, i am 100% in agreement. i’ve been doing that for years and have one set each for mom, dad and myself which are even color coded. i also maintain a smaller clearbook, per individual, for prescriptions. each of us already have 3 to 4 volumes of medical records to date. inside are records, as far back as the mid 80s, of medical procedures including lab works. all the doctors who have seen my books have expressed their wish for other patients to do the same. since you’re quite techy, you might want to go one step further. you can scan and upload your records onto your ipad. this is a good alternative to bringing volumes and volumes of clearbooks with you during hospital visits.

    thanks for your updates and keeping me in the loop. for a non medical personnel, i am learning a lot in the process.


  2. rojoson says:

    Will strongly consider your suggestion on list of medications.

    Thank you for sharing your experience on the use of clear books and the suggestion on digitalization. My suggestion was just on scanning for back-up purposes. You have gone one step further – using ipad to communicate with the doctors on the records thereby avoiding the inconvenience of bringing along the hard copies. There is one limitation I see with the use of ipad during communication with the doctors. Not all doctors are as techy as I am. It is good that I have a computer in my clinic. There are some patients who brought CDs to their doctors sans the hard copies or the plates (x-ray, CT scan). Without a computer, the receiving doctors will be helpless when presented with the CDs.

    With the present trend of diagnostic procedures being presented in digital forms, all medical clinics and medical doctors have to have computers to view these and learn how to view, if not interpret, them using the computers. Honestly speaking, I am still at the stage of trying to learn how to read the results of the imaging procedures in my computers.

    Merry Christmas, Lou.

    Dr Rey

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