Medical records and correspondence demand respect

To The Editor: I was amazed recently to see a patient from Libya who came to the UK for treatment based on the advice of his Libyan physicians. The patient carried with him no referral letter whatsoever. Not one physician familiar with his case bothered to write a few lines for the poor patient, although each of those doctors saw the patient at least twice and prescribed one or more treatment. The patient carried with him different medications that had been prescribed, and a few empty containers of other medicines he had used. I mention the above short tale to bring to light what I feel is a major ethical problem with the way medicine is practiced in Libya [1]. The keeping of good medical records together with clear and concise correspondence between physicians is imperative for several reasons. Not only does it avoid duplication of services and unnecessary costs, it decreases the time invested by both the patient and physician, and it fosters a collegial relationship among healthcare providers. Many times, referring physicians may not know each other. It provides a channel for them to learn from each other as well as a method for them to form professional relationships. It occurred to me that colleagues in Libya may be shy of writing referral letters or may even be phobic about disclosing their practice habits. Patient information can best be written as referral letters which summaries the patient presentation, testing, response to treatment, possible consultation, and reason for referral. The referral may be because the physician(s) initially treating the patient simply have tried all treatments known to them, or they may need to refer if they lack certain diagnostic equipment necessary to continue the care. To refer the patient to colleagues simply says " we think more can be done for this patient but we may not be able to do it here; please evaluate. " It shows respect for the patient and for the colleague. No physician knows everything there is to know or has every diagnostic tool available. I understand from speaking to doctors who practice in Libya that medical documentation is rudimentary. If it exists, it lacks clarity, continuity, confidentiality, and accountability. Doctors fail to sign and date their orders if they enter them in patients' notes [2]. Relaying patients' information to colleagues is mainly done verbally without much documentation [3]. People who need to go …