Chapter 23: Your Medical Records: Vital Statistics
|The horror of that moment, the King went on, I shall never, never forget! You will, though, the Queen said, if you dont make a memorandum of it.
- Lewis Carroll
Its 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 doctors 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 doctors 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 dont, please ask your doctor to explain it to you! While it is the doctors responsibility to provide you with this information on a routine basis, its important that you ask for it after all, its 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. Dont 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 ; theyll 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 !):
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
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: