Introduction of a uniform record keeping practice for rheumatology clinics in Sri Lanka—an ILAR project

In Sri Lanka, record keeping in rheumatology clinics is purely paper-based. Clinic record books are given to patients, and the hospital does not retain clinical data. Different clinics and different rheumatology specialists practice different formats of record keeping in Sri Lanka. This project was aimed to develop a uniform record keeping system which can be used in all government rheumatology clinics in Sri Lanka. Project was carried out in two phases. First phase was carried out in seven rheumatology clinics to identify deficiencies in existing practice of record keeping in rheumatoid arthritis (RA), spondyloarthritis (SPA), and systemic lupus erythematosus (SLE). Second phase was to develop new clinic documents and a computer-based system, using the findings of the first phase. Recording of classification criteria at the time of diagnosis was 40.6% for RA and 90.3% for SLE. Initial clinical notes were not available in 18.3% of RA patients. Recording of individual classification criteria in SPA was ranged between 10% and70%, and it was 100% for arthritis. During second phase, new paper-based and computer-based record keeping systems were developed. Existing practice of record keeping is incomplete, especially in RA and SPA. The necessity of new, uniform record keeping system was recognized. Paper-based and computer-based record keeping systems acceptable to specialist rheumatologists, medical officers, and the Ministry of Health were developed and tested. The newly developed paper-based system is being used nationally while the electronic system is yet to introduced.