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Chapter 23: Your
Medical Records: Vital Statistics
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'The
horror of that moment,' the King went on, 'I shall
never, never forget!' 'You will, though,' the Queen
said, 'if you don't make a memorandum of it.'
- Lewis Carroll |
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It's a sad fact of life that most people devote
more time and energy on organizing their bank statements,
than they do on their medical records. They simply
club together their prescriptions, chemists' bills,
lab reports and doctor's findings, leading to an
unwieldy and disorganized hodgepodge of papers,
from which it is difficult for them (and their doctor!)
to retrieve any useful information without wasting
precious time. This state of affairs is very unfortunate,
because only accurate medical records can help you
to get the best medical care. Remember that maintaining
a personal health record at home is one of the best
ways of ensuring that you will have upto date information
about your health at all times
Since a doctor's diagnosis is based primarily on
your medical history, your ability to provide complete
and accurate information is crucial in ensuring
you get good medical care. That is why you need
to devote adequate time to organizing your medical
records before you consult a doctor, so that you
can answer his questions completely and accurately.
This first step is to file all your papers in reverse
chronological order i.e., the oldest ones last,
and the newest ones first. It is a good idea to
number the documents, to make sure they are all
in order. Large-sized reports such as, X-rays and
scans need to be carefully stored in a separate
oversize file. Keep bills and envelopes separately
if needed; these items need not be part of your
medical record! If you have ever undergone surgery
or hospitalization, make sure you get a complete
discharge summary from the doctor, as this is information
could prove vital in the future. If you do not get
this information soon after discharge, it may be
irretrievably lost and this loss can prove to be
rather expensive to you! Make sure you understand
fully the condense of the discharge summary; if
you don't, please ask your doctor to explain it
to you! While it is the doctor's responsibility
to provide you with this information on a routine
basis, it's important that you ask for it after
all, it's your record! If you change doctors, your
present doctor should give you all your medical
details, so that you can provide them to your new
doctor. You may find your present doctor is reluctant
to part with the information (after all, he may
not want you to go elsewhere), but you need to assert
your rights. If your file becomes very thick (as
it may if you have a chronic illness), it is a good
idea to summarize your medical history on a single
sheet of paper, and to update it on a regular basis,
as needed. Your doctor can help you to prepare this
summary to make sure it is accurate and contains
all the relevant information. A sample of a form
which you can use to track your medical history
is given in Appendix 1.
Your medical record must also contain information
about the following:
Allergies. List all
your allergies and sensitivities, especially to
medicines, foods, and chemicals.
Medications. Make
a list of all drugs that you are presently taking.
Don't overlook oral contraceptives, nonprescription
medications (such as allergy pills, vitamin and
mineral supplements), and alternative remedies such
as herbal preparations. Include appropriate details
on dosages and brand names.
Previous adverse reactions to drug or side-effects.
This knowledge is very important because many medications
are chemically related to each other.
Pacemaker or any other implanted
device. This information is important because
some examinations, such as magnetic resonance imaging,
should not be done on patients who have certain
electronic or metal devices in their body.
Any forms of treatment you are now undergoing. In
addition to describing other medical treatments,
be sure to include any home remedies or alternative
therapies, such as dietary remedies, enemas, herbal
or natural medicines and homeopathy.
In addition to your own personal medical history,
pay particular attention to your family tree. In
order to construct a family medical tree, carry
out research on your parents, siblings and children.
Then add information about grandparents, aunts uncles,
cousins, nieces and nephews. The more relatives
you include, the better. Be prepared to do a bit
of detective work when filling in the relevant details
in your family tree. Most families so have an unofficial
family historian who can provide information about
the health and longevity of previous generations.
The family tree should ideally depict all the relatives
, the diseases they had, the age at which these
developed, when they died, and what they died .
Make copies of this family tree and distribute them
to other family members ; they'll appreciate your
gesture! This information can be invaluable in developing
a preventive approach towards health maintenance.
A family history of heart disease, high blood pressure,
and other common killers that appear to have a hereditary
component can alerts you and your doctor to your
increased vulnerability, so that you can tailor
your lifestyle to minimize your risk. You may also
be advised to undergo more frequent medical checkups.
If, for example, you detect a family history of
colon cancer, you may be advised to undergo periodic
colonoscopy or other screening examinations for
this disease, even if you are free of symptoms.
Many inexpensive computer programs are now available,
which can help you to record your medical history.
Not only do they ensure that your record is complete
and legible, but they also allow you to update it
easily. Such a programs are well worth investing
in, if you own a computer !
You should keep all your medical records in one
safe, and easily accessible place, along with the
following information ( this can save your life
in a medical emergency !):
- Person to notify in an emergency.
- Name and phone numbers of your doctor, dentist,
optometrist and chemist.
- Current medications you are taking.
- Organ donor authorization details.
- Health insurance information
Understanding your hospital
medical record.
What about your hospital medical records ? These
can be voluminous documents, and it may find it
difficult to make sense of all the papers , reports,
forms and charts in them. However, once understand
the structure of the records, you can comprehend
the details more easily.
Documents Common to Most Health Records
- The Identification Sheet is a form that originates
at the time of admission. This form lists your
name, address and telephone number.
- The document on History and Physical/Clinical
findings describes factors such as:
- any major illnesses and surgeries you have
had;
- any significant family history of disease;
- your health habits; and
- current medications. In addition, it usually
specifies your height, weight, blood pressure,
pulse, respiration rate, any particular symptoms
you may have described, and details of your
physical examination.
- Progress notes are notes made by the doctors,
nurses, and therapists caring for you that reflect
your response to treatment and their observations
and plans for continued treatment.
- Consultation is an opinion about your condition
made by a physician other than your primary
care physician. Sometimes, a consultation is
performed because your physician would like
the advice and counsel of another physician.
At other times, a consultation occurs when you
yourself request a second opinion.
- Physician's Orders are contained in a document
which records your physician's directions regarding
your medications, tests, diet and treatments.
- Imaging and X-ray Reports are documents describing
x-ray results, mammograms, ultrasounds, or scans.
The actual films are usually stored in the radiology
or imaging departments.
- Electrocardiogram (ECG, EKG) reports.
- Lab Reports describe the results of tests
conducted on blood, sputum, urine and other
body fluids. Common examples would include a
urinalysis, complete blood count (CBC), cholesterol
level and throat culture.
- Authorization Forms include copies of consents
for admission, treatment and surgery.
- The Operative Report is a document describing
the surgery performed and gives the names of
the surgeons and assistants involved.
- The Anesthesia Report is a form documenting
the pre-operative medication, anesthesia given,
and the response to anesthesia during surgery.
- The Pathology Report describes tissue removed
during an operation (if any) and gives a diagnosis
based on the examination of that tissue.
- The Graphic Sheet is generally a graph used
to plot your temperature, pulse, respiration,
and blood pressure over a particular period
of time
- The Discharge Summary presents a concise account
of your stay, which includes the following information:
the reason for admission; the significant findings
from tests; the procedures performed; the therapies
provided; the response to treatment; the condition
during discharge; and instructions for medications,
activity, diet, and follow-up care.
Some nurses and doctors still do not know that patients
have the right to see their own medical records.
To avoid the being victim of a misinformed medical
professional, it is vital that you know your rights.
In fact, some consumer advocates argue that it is
a good idea for patients in a hospital to take a
look at their own medical charts routinely, to make
sure that the doctors and nurses have written down
everything accurately; after all, medical notes
can be inaccurate or incomplete, leading to confusion
in the future! How do you go about getting copies
of your records? Simple: just a your doctor! Remember
that you have a legal right to your medical record,
and, while technically, the documents belong to
the hospital, in most cases, the information about
you belongs to you. Of course, the hospital may
charge you for making copies, and you will need
to pay the required amount.
While your records are very helpful in improving
the quality of your medical care, do not forget
that they can also prove extremely important in
case you are unhappy with your medical care, and
need to complain about your doctor or hospital,
since these records can be used to support your
claim. They are also vital when you need to claim
reimbursement for expenses for medical treatment
from your insurance company.
To put the importance of your medical records into
perspective, remember that records serve many purposes.
For instance, these records provide:
To put the importance of your medical records into perspective, remember that records serve many purposes. For instance, these records provide:
- The basis for planning your care and treatment.
- A means of communication amongst the many health professionals who contribute to your care .
- Basic data for health research and planning.
- Verification of services and treatment covered by your insurance.
- A legal document describing the care you received.
Make sure you take extremely good care of your medical records - they can help
you to get good medical care in return!
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