You must be actively involved in making decisions about your own body. If you don’t understand the medical gobbledygook, the fault is not yours -- it’s the doctor’s
What Information should Your Medical Records Contain?
- Unique identifiers such as your full name, ID proof etc.
- Demographic data including your address, phone number(s), and email address.
- Known medical conditions, allergies, drug/alcohol/smoking habits
- Your doctor’s records of your visits, diagnoses, treatments, diagnostic test results, prescriptions, and referrals to other doctors.
- The health of your immediate family members, particularly parents and siblings, and whether there is a history of certain diseases.
- Billing and payment information, such as the party responsible for payment, health insurer, and primary beneficiary.
A good doctor must respect your intelligence, your desire to learn about your medical condition and your ability to understand what procedures he intends to carry out on you, so that you both can work together as a team in order to find the best therapy available for you. If your doctor doesn’t have the time or inclination to do so, or if your communication with your doctor is like a one-way street, then this is a red flag that you need to find a new doctor who is willing to actively engage you in your medical care. If this is not possible, consider hiring a patient-advocate who will help you make sense of your illness.
Good doctors encourage your participation in your healthcare, so that you can make an informed decision about what is right for you, according to your personal circumstances, beliefs and priorities. For this to happen, you should also strive to gain knowledge about your health problem. Being passive and dependent upon your health care provider for all your treatment decisions will not help you get the best medical care. You must do your own homework to find out what your options are, so that you can make a well-informed decision, and select a treatment protocol that you are comfortable with; which will improve your quality of life and maximise your chances of a good outcome.
When you are in hospital, here is what you need to know about your medical records: Make sure you have copies of all your medical records- they are legally your property. You can give the doctor photocopies of your original reports for his files but keep the originals with you. They are worth their weight in gold. Also make sure that you understand what’s in your medical records- you must be able to make sense of your doctor’s hieroglyphics,, so you can explain your diagnosis and treatment to another doctor, if you need to take a second opinion.
Read up on your condition:
Read as much as you can about your problem. A good doctor will arm you with printed material to read at home.
Read up on the doctor:
If you think you are not receiving the information or the level of care that you are entitled to, you can demand a transfer to another facility.
Remember that you are always free to seek discharge against medical advice, if your dissatisfaction with the doctor or the hospital is extreme. You may be asked to sign a ’Discharge against Medical Advice (AMA)’ form, but you can’t be forced to stay in the hospital against your wishes - and if the hospital tries to do this (for example, by insisting that you have to clear all your hospital bills before they will let you leave), they are committing a criminal offense).