The Card System in Medical Practice.

BY CARL E. BLACK, M. D.

JACKSONVILLE, ILL.

Surgeon to Passavant Memorial Hospital and Our Savior's Hospital; Surgeon to the Chicago & Alton Ry. and the Chicago, Peoria & St. Louis R. R.

TH

HERE are many reasons why every physician in active practice, be it either general or special, should keep a record of his cases including the history, diagnosis, progress, treatment and outcome. Such a plan is indispensable for our own education. It is the only way in which we can know from month to month and year to year what we are doing. Only by such a plan can we secure reliable statistics of cases in general practice. At present nearly all our conclusions are based on hospital records, but it is well known that cases in private practice and hospital practice have wide differences. Accurate records by a thousand observers in isolated country districts, for example, would undoubtedly throw new light on many diseases. Only by record keeping and case study can we know

our work.

This paper is written for the purpose of showing how doctors may better conserve their time and energies and is in response to many inquiries I have had regarding the card system as adapted to the needs of the busy practitioner. The duties of life have become so numerous and exacting that the old methods of cumbersome record books or record sheets must give way to new and more progressive ones. The doctor whose whole armamentarium consisted of saddle-bags and lancet has been forced to adopt modern offices with full modern equipment, as the selfmade doctor, without college education or medical degree, has been replaced by the M. D. produced by four or five years of graded study in a thoroughly equipped college with from ten to fifteen practical working laboratories.

These changes have produced men who must do more work. They do not necessarily see more patients, but give each one far more attention. This is an age when the details must be cared for, and they are multitudinous.

The duties of an ambitious and conscientious physician are so numerous and much of his work so purely an individual and personal matter that he must resort to many time-saving devices or fall behind at some points. Some of the questions which present themselves are, how can he carefully look after the business side of his profession, that is "keep books" so that accounts will always be posted and statements ready when called for; keep careful records of his cases with signs, symptoms and diagnosis, record operations with their findings and results; read, analyze, classify and assimilate his current medical literature, and have it at hand for ready reference; prepare papers and attend to the various other duties connected with medical societies; give careful attention to correspondence, and keep accessible what one writes, as well as what one receives; and keep invoices and receipts carefully and properly filed. This indicates briefly the topics which will be taken up in this paper.

Any system, to be successful, must save time and energy, or what amounts to the same thing, or is better, it must enable us not only to save our time and energies, but must also enable us to increase the quality, as well as the quantity of our accomplishments. If it does not do this it cannot be considered successful. This must be the test for what follows.

It goes without saying that such a system pre-supposes the use of cards instead of books. The day of books for such purposes has passed. If not fully convinced on this point a few hours investigation of any thoroughly up-to-date public library, and of a few business houses using modern methods, will serve to finish the conviction.

The card system is not altogether new, as slips and cards were used in France in the seventeenth century, and have been more or less in use ever since. They were usually, however, temporary expedients. Their use for permanent records is of more recent origin. The development of the modern card system is American. Much of its development is due to Melvil Dewey and the Library Bureau. For fifteen years this was the only concern which manufactured cards and other accessories to the card system, exclusively. To them through the American Library Association is due the credit of establishing uniform standards of size, which is an exceedingly important matter. While cards were first used in museums and later in libraries, they are now used in every business and trade, and each year sees them adapted to new uses.

The foundation elements of a card index are, first the card, second the guide, and third the box or drawers in which these are contained. In Fig i, you will find these elements illustrated.

The data which you wish to record is on the card, and the guide which stands up above the cards, carries an index letter and is simply an aid in finding a given card quickly. The more guides properly distributed, the more readily the cards are found. These foundation elements are subject to great modification.

It is not my intention to discuss the theory of card using, or to enter into any detailed account of the various forms on the market and the uses to which they are adaptable. I will simply relate my own method of using cards and illustrate the various card forms, indexes, and cabinets, which I

have in actual daily use, fully realizing that it is far from perfect. I use card indexes for five principal purposes:

a. All bookkeeping, including the ledger.

b. All records of cases.

C.

Topical index to current medical literature.

d. Alphabetical index to authors in current medical literature.

e. For the systematic filing of correspondence, invoices, receipts, catalogues, etc.

Bookkeeping-All my cards for whatever purpose are of a uniform size. The 33L card (3 x 5 inches) is the one used. Its actual size is illustrated in the cuts. A common mistake made by beginners in the use of cards is the adopting of too large a size. The experience of our librarians who are the most extensive users of cards, for numerous purposes,

Diagnoors
Complaints

Treatment.

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FIG II.

General card for accounts and record.

should be some guide. This size card has been adopted as standard by the American Library Association, while cards of various sizes are in use the 3 x 5 card is the only one which has been formally adopted by any organization as "standard." The library of congress and various government departments also use this size card. It will be noticed that the first four lines of all the cards are for bookkeeping purposes, and provide space for the name, and residence of the patient, the date, the character of services rendered, and the amount charged, with an additional line for entering any credit. For convenience in charging for services this is on all the cards.

The special advantages of cards for bookkeeping is that they are simple, accessible, accurate and expansive The cards are small enough to fit

the average pocketbook, and can always be carried in the pocket. In this way you have your card of original entry always with you. Visits can be recorded at the bedside, with amount charged and date. These never require transferring to any other card or book, which insures accuracy in accounts. A new card is used for each service rendered the patient, or at least for each day.

Record Keeping. The time has gone by when the progressive physician can afford to neglect his records. If it is business-like and necessary for life insurance companies, gas companies, and other purely business organizations to keep accurate records of their affairs, it is equally necessary and desirable that the physician should keep an accurate record of the conditions affecting his patients and the treatment applied.

Record keeping is no longer subject to argument as to its desirability, or even as to its necessity. It is simply a question of how these records can be most accurately and conveniently kept. In the International Clinics, Vol. 4, 11th series, 1902, the "Methods of Keeping Records in Private Practice" is discussed by Frederick A. Packard, Judson Daland, John H. Musser, J. P. Crozer Griffith, J. K. Mitchell and Alfred Stengel. These writers fully realize the necessity for more systematic study of our cases. The only way to do this is by systematic record keeping. Many of the plans which have been devised for record keeping, fail by their own weight. They are too voluminous and cumbersome for the busy physician to use, and he abandons them in desperation. Here again we fall back upon the simplicity and adaptability of the card system.

By referring again to the illustration of the various cards which are used it will be noticed that each one provides space for the record, but that the record and the account are provided for on the same card. In this way, one card with one entry of the patient's name answers both purposes. The smaller card is more desirable for this purpose, because many of our entries will be very brief, and for the few which are long, several cards can be used.

Fig. II illustrates the simplest form of card and provides for a brief memorandum of the complaints of the patient, followed by the treatment or prescription given.

The reverse side of the card can be used if more space is needed. If a written prescription is given the patient, a carbon paper will save the necessity of copying.

For any case which requires more investigation the card illustrated in Fig. III should be used first. This provides for a brief memorandum regarding the personality of the patient, and a record of previous illnesses.

Fig. IV provides for the family history of the patient, and should be used where a more searching inquiry is begun.

For memorandum of physical examination the card shown in Fig. V is used. It is usually necessary, however, in using this card to supplement it by blank cards. For example, we may find the circulatory system greatly at fault, while there is very little to be recorded regarding the glandular, respiratory, digestive, integumentary, motor, urinary, generative or nervous systems. In such case we use card No. V for making a brief memorandum as to the condition of each of these systems, while for the circulatory system, which is most at fault, we use Fig. II for

making the detailed entries of the pathological circulatory conditions. It would be still better to have a special form for each system. Special cards can be used for sphygmographic tracings, temperature charts, etc.

Name up Health Cause of Death a duration of Illness Previous Health

Father

mother

Lurner

Brothers

De

Have parents grand parents brothers sustere un clas or aunts had con Sicofula Conca Incanity (pelepey Yout Aheumatism?

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FIG IV.

Family history card.