Personal Health Records

 


filling out formsHow often have you found yourself sitting in a waiting room with a clipboard balanced on your lap trying to put complete answers in too small a space, all the while worrying that you’ll leave out something important?

All doctors and hospitals ask for much of the same information at your initial visit or when you seek treatment in an emergency room or urgent care center. Schools need similar information in order to act in the best interests of your child in the unlikely event of an emergency occurring while at school. Preparing it in advance benefits all involved, especially the patient. The information will run several pages, but you will have a complete history to hand over so you and the doctors and nurses can then focus on why you came to see them. The typed information will be easier to read and you will be confident that you have not left out something important.

Begin with the Basics

On the first page list patient’s full name, date of birth, address, and telephone. Parents should then list their names and contact information. You should also provide contact information for at least one other person who will always know how to contact the patient’s primary caregiver. Next write the name and contact information of the patient’s primary care physician (family doctor or pediatrician). Copy all of the information from your insurance cards and make copies of the actual cards.

 

Medications

Next create a page listing all medications. On the first line type ALLERGIES and list all known food and drug allergies. Then list all the medications the patient takes. Include non-prescription medications, vitamins, and nutritional supplements. Take out all the medicine bottles and copy the information from the labels: medication name, dosage, frequency, and name of the doctor who prescribed it. Example:

furosemide 20mg – take one tablet by mouth 2 times every day – Dr Smith

Be sure to include medication infusions you go to the clinic or hospital to receive or are given to you by a home health nurse. If you have an infusion port like a PICC line, Hickman, or Port-A-Cath, write the type and location on your medication list. Supplemental oxygen is also a medication and should be included on this list, noting how many liters per minute and if you require mechanical support during sleep.

 

Medical History

The next page will summarize the patient’s medical history. On this page make a list of conditions the patient has been diagnosed with, major illnesses, illnesses requiring hospitalization or ongoing care, and surgeries, including the dates and physician’s name and location, beginning with the most recent. Here is an example:

2007 January  – lymphangiomatosis – University Children’s Hospital/Dr. Smith

It is not necessary to include every doctor’s office visit in this summary, nor is it necessary to include illnesses such as strep throat and influenza unless they were serious enough to result in hospitalization. If the patient has many medical conditions or numerous surgeries, separate pages for the diagnosis list and surgery list may be helpful.

 

Test Results

Now list all the tests done to diagnose and monitor the lymphangiomatosis/Gorham’s disease and any other major diagnosis, such as heart conditions or asthma. Be sure to include the area examined, where the test was done, and the name of the doctor who ordered the study:

2011 August – CT chest – City Children’s/Dr Brown

It is not necessary to include blood tests in this list. If the patient has a blood component that is abnormal on a regular basis, it is adequate to make a note something like this: white blood cell count usually below normal.

 

Care Providers

The final page will list the full names of all the doctors whose names appear in the file and how to contact them. Typing the names in BOLD CAPS makes it easier to scan the list for a given doctor.

These are the basics. This information should be updated each time your medication changes, you have a test or procedure done, or see a new doctor and you should keep a copy of it with you at all times. Print a fresh copy and take it with you to every doctor appointment. Also take copies to your child’s school and give one to the school office and one to the school nurse.

 

Storing and Sharing

Now let’s talk a bit about how to store and share this information. Most new word processors enable you to save files in the pdf format to allow reading on any computer. There are a number of ways to store and share the file to ensure you can always access it:

 

  • upload the files as attachments to your profile in the LGDA Patient Registry
  • put a copy of it on a flash drive attached to your key ring
  • sync a copy on your smart phone
  • email a copy of the file to yourself so you will be able to access it from anywhere with a computer or smart phone
  • upload the file to Google Docs so it can be accessed over the internet

Another effective way to store and share the information so it is accessible to medical personnel in case of emergency is to register with MedicAlert and wear the identification bracelet that is engraved with diagnosis, allergies, and a personal identification number along with their 24-hour hotline number. Emergency medical personnel look for these identification bracelets, then call in the ID number and MedicAlert sends the information in the file to the medical provider. For a small annual fee you get peace of mind that, as long as that bracelet is worn, any medical provider can access information about your medical history.
 

 

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