Personal Medical Record

      This chapter provides a six-step system to organize your health care information so it can be easily communicated to any health care provider. 

     Health care responsibility is a process that starts with understanding your medical history and ends with receiving great health care.  This process involves organizing your past medical history and understanding your future health care needs.  It is an ongoing process requiring an initial investment of time and energy to complete the personal health record.  After the record is set up, it is updated at each health care encounter or with any change in care. 

     This system allows you to become an expert in your personal health care.  Maintaining your record permits easy transmission of information to health care providers and assures you are in line with national recommendations of health care.  

     Communication is a vital step to good health care.  Face to face contact time with health care provider is limited and each person needs to know how to maximize this time.  Good communication is partially accomplished by being organized and helps overcome the shortcomings of the modern health care system.  The personal health record system outlined here improves communication with the health care system. 

     The doctor visit is a business transaction.  Use this very valuable time wisely and transmit essential information.  This does not mean that you should be unfriendly but use the time wisely.     Taking an active role in your health care; maintaining a person health care record provides a sense of power and assures you are getting appropriate care. 

Medical Record  

     Medical records are complex and contain multiple pieces of personal and medical information.  It is a vital that every health care provider has full knowledge of your medical history.   Being able to transmit this information to the health care system bestows a distinct advantage in getting the best health care.  

     The personal health record, which is similar to a medical chart that a physician or health care system would keep on you, guarantees you are receiving the best health care possible.   With the fragmentation of the health care system it is important to have all health care information in one spot.  Maintaining your health record allows you stay organized and transmit accurate information to your health care providers.  

    All of your physicians and every health care setting, such as hospitals, nursing homes and surgical clinics, keep a copy of your medical record.  Your medical record contains items that pertain to your health such as doctor’s notes, lab work, surgical reports, and radiological exams.    Your personal health record contains all things contained in a medical record – but more.  The personal health record assures that all of your health record is stored in one place.  No more worrying about if your primary care doctor did not get a copy of a lab test or diagnostic procedure – you will have a copy that you can share.  

     Medical records are often incomplete.  If you receive services from another health care provider or health care system, this information is likely not known to your doctor.  Communication within the health care system is not optimal; each individual must take that responsibility upon himself or herself.

Table 1: The importance of maintaining a personal health record

   Here is a list of what you should keep:

• Demographic information including your name, address and emergency contacts
• Insurance information
• Social information including marital status, employment history, smoking, alcohol and drug history
• Immunization history: Documentation of all received vaccinations
• Drug and food allergy and your reaction to those substances
• Medical diagnoses and the year you were diagnosed
• Surgeries and the year they were performed
• Family history.  Report the medical history of your parents, siblings, and children.  Record any illness, the date of illness onset, and cause of death and age of death if applicable.  If the family member is still alive - record his or her age.
• Hospitalizations, including the dates, diagnosis and treatments. 
• Procedure notes.  A copy of the report of all procedures that you have had including, but not limited to colonoscopies, stress tests and biopsies. 

·         Doctor lists.  Record the name and number of all the doctors who are currently treating you. This includes your primary care doctor, any medical specialists, your dentist, eye doctor, chiropractor and podiatrist.

·         Medication lists.  To accurately prescribe new medicines or evaluate your medical condition, health care providers needs to know exactly what medicines you are on.  The medication list should include all prescription and over the counter drugs that you take routinely or on an as needed basis.  In addition to the current mediation list, it is helpful to have a list of all old medications that you have taken in the past.  This list should include the name of the drug you have taken, when it was taken and why you are no longer taking it. 

·         Diagnostic procedures include x-rays, CAT scans, MRIs, echocardiograms, electrocardiograms and ultrasounds.  Obtaining a copy of each of these tests helps the physician know what previous tests you have had so there is no duplication of testing.  It also assists the doctor in understand what diseases have already been tested for.

·         Lab work.  Laboratory tests are very common in health care.  Patients get laboratory evaluation for a variety of reasons including, assessing an acute illness, monitoring a chronic disease or screening for certain diseases.  Tracking labs overtime assists the health care provider in monitoring disease. 

·         Preventative health monitoring.  Many preventative health tests are not preformed as recommended.  Keeping a list of what and when testing is needed assures you are getting all recommended tests.  This information is detailed in Don’t Get Sick: Seven Steps to Optimal Preventative Health Care.

·         Doctor visits.  A section of your health record should includes each or your physician visits.  This is detailed in chapters 2 and 3.

·         Chronic disease monitoring.  Each individual has a unique combination of chronic diseases. Monitoring these diseases assures that they are cared for properly. This information is detailed in Chronic Disease Guide: How to Prevent and Treat Common Chronic Diseases. 

The Six Steps 

     Using the attached spreadsheet to this ebook will allow you to set up your personal health care record.  The first step involves getting a three ring binder to place the forms needed to complete your record.

     In the front page of the three-ring binder you should place the personal health care record table of contents to help you organize your information.  The three ring binder should be broken down into six sections.  Get 14 dividing sheets with tabs so the three ring binder is neatly organized.  You can print copies of the forms in the attached spreadsheet and the Appendix.  Here is a list of sections you will create. 

1. Health History (Spreadsheet – worksheets 1-3 for adults and worksheets 1-4 for children)
2. Medications (Spreadsheet – worksheet 4 for adults and worksheet 5 for children)
3. Preventative Health Care (information for this section is detailed in Don’t Get Sick: Seven Steps to Getting Optimal Preventative Health Care)
4. Diagnostic Testing  - obtain hard copies of all tests.  Ideally you should have tabs to break section four up into these four sections. 

a)    Laboratory

b)    Radiology

c)    Procedures

d)    Surgeries

5. Health Care Encounters – obtain a note from the doctor or use one of the forms in chapter 2 and 3.  Ideally you should have tabs to break section five up into these three sections.

a)    Doctor Visits

b)    Emergency Room, Urgent Care and Retail Health Visits

c)    Specialty Doctor Visits

d)    Hospitalization/Nursing Home

6. Chronic Disease (See Chronic Disease Guide: How to Prevent and Treat Common Chronic Diseases for more information on specific forms for the chronic disease section. 

Step One – Health History

       The first section is an overview of your health; it includes demographics and a medical history.  The form to record this information is found in the attached spreadsheet.  Step-by-step instructions are listed below but most of the questions are self-explanatory. 

Steps for the adult form:

• Fill in your name, date of birth, address, phone number, email address and gender.
• Fill in your marital status: married, single, divorced, widowed, or living with a significant other.
• What is/was your occupation?  Are you retired? Did you work with any chemicals or hazardous materials during your professional career? Which ones?
• Record your height and weight and date you recorded that weight.
• What is your religious background?  For example, Catholic, Hindu, Jehovah Witness, Muslim, Protestant, etc.
• Report your ethnic background on your mother’s and father’s side if known. For example, Mother – Hispanic/American and Father Asian/American.
• Tell if you are a smoker.  Put a quit date if you quit.  Estimate the number of packs of cigarettes you smoke (d) on an average day.  How many years did you smoke? Fill in any other tobacco use including pipe use or chewing tobacco.
• How many drinks do you consume?  Write in the number and how often have that number of drinks per day, week, month or year.  How long have you drank alcohol?
• Have you ever used or do you currently use any recreational drugs such as marijuana, cocaine or LSD.
• What is your blood type/Rh type?
• Fill in a primary and secondary emergency contact.  Pick someone you would want a health care professional to contact in case you are in a serious accident and are unable to speak. Please fill in name, contact information and relationship.
• Fill in the name of the person that you have chosen to be your power of attorney (if applicable) for health care and where you filed those papers.  
• Fill in information on your advanced directives?
• List all of your doctors utilizing the doctor list form.
• Fill in the information on your primary and secondary health insurance policy.
• List all of your medical conditions and the date(s) that you were diagnosed. There is an extra space at the bottom of the section to report any diseases and infections not listed on the pre-printed forms.
• List the dates of your immunizations.
• Keep a running tab of you doctor visits including primary care doctor visits, specialists visits, vision appointments and dental evaluations. Fill in the information on the form for each visit. 
• List all of your hospitalizations including the dates you were in the hospital, the name of the hospital, reasons you were in the hospital, diagnosis and treatments you received. 
• List all of your surgeries or any devices that that you have had and the date(s) they were performed.
• List all of the laboratory evaluations that you have had. 
• List all of the diagnostic tests or procedures that you have had including x-rays, CAT scans, colonoscopies, biopsies, angiograms or endoscopies and the date.  Obtain copies of these procedures for your medical record (section 4).
• List the diseases and the age at diagnosis (if known) of your first-degree relatives including cause of death and the date of death, if applicable.  A first degree relative is defined as a parent, sibling (brother or sister) or child.  For example, Mother – High blood pressure diagnosed at 50, diabetes diagnosed at 60, died at 82 from a heart attack.  

Step Two

     Next, complete the medication list (sheet 4/5 on the attached spreadsheet).  The medication list includes the name and dose of each medicine that you are taking as well as the times of the day that you take it and the reason that you are taking it. 

     Fill in all of your allergies.  Report the substance/medication that you are allergic to, the reaction that you had, when it last occurred and what type of treatment was implemented to combat the allergy. 

     Another page should be filled out, to the best of your ability, as to your medication history.  Medication histories are medications you were on in the past.  Include the name of the medicine and dose you were on and the date it was started and stopped.  Provide a brief explanation as to why it was started and why it was stopped. 

Step Three

     Preventative health care is a key component to good health.  It entails testing, medications and lifestyle choices to prevent disease.  Part of preventative health care is healthy living, which includes regular exercise, good nutrition, not smoking and using alcohol in moderation or not at all.  

    Review the preventative health care worksheet and note the dates of the previously attained exams. If you are outside the recommended range on the form – discuss with your doctor.  See instructions on completing this form in Don’t Get Sick: Seven Steps to Optimal Preventative Health Care.

Step Four – Diagnostic Testing/Surgery

     Section four is a place for patients to record all diagnostic testing.  This is the same information as recorded in step one, but this is a section for you to keep a hard copy of this information. Every time you have a test, of any kind, get a copy for your personal record. This section can be broken down into four sub-sections:

• Blood work
• Radiology
• Procedure/Diagnostic Testing
• Surgery

      Include blood tests that your doctor has taken, included complete blood counts, kidney function tests, electrolytes such as potassium and sodium, liver tests, thyroid test and cholesterol tests.  Include tests taken over the last 5 years. 

     It is not necessary to include every lab report.   For example, during hospitalization there are often daily blood tests and including each of these will not benefit any health care provider.  Also, patients who are on coumadin get blood tests monthly and sometimes more frequently.  It is not necessary to include each of these blood tests.  Try to obtain at least one - the most recent one - of the following:

Complete blood count

Kidney test/electrolyte

Liver function tests

Thyroid test

Cholesterol level

     Radiology reports include x-rays, ultrasounds, CAT scans, MRIs, mammograms, and PET scans.  It is not necessary to place the actual film in your record, but a written report of the interpretation.  After one of these tests the radiologist interprets the test and provide a written interpretation of the report.  Ask your doctor for a copy of the report

     Diagnostic tests include a variety of procedures including stress tests, electrocardiograms, echocardiograms, pap smears, pulmonary function tests, etc.  Each test or procedure that someone has is accompanied by a written interpretation by the doctor.  Include this written report in the health care record.  

      It should also include a list of all of your procedures.  Each procedure that is performed will have a written explanation.  If you have had a diagnostic procedure such as a colonoscopy, endoscopy, angiogram, mammogram or biopsy, obtain a written copy of the report.

     Every surgery is accompanied by a written report.  Obtain a copy of any surgical report from your surgeon. 

Step 5 – Doctor Visits

     This section is a place for you to keep records of your health care encounters.  This section can be further sub-dived into primary care visits, specialist care and hospital/nursing home stays.  Each doctor visit can be classified as and acute visit, follow up visit or maintenance visit such as an annual exam.  The appendix has a form for each type of visit (this will be explained in chapter 2 and 3) .  For each doctor visit one of these forms should be filled out.  The form will not only allow you to have a good health care encounter but serves as a record for future reference.  See chapter two for more details.

     The hospitalization record includes a summary of each or your hospitalizations.  Some hospitals provide discharge summaries that sum up the hospital stay.  If you can get your hands on these discharge summaries this is an ideal item to put in your personal record.  If you are unable to get this, a form is provided in the appendix that allows you to record vital information about your hospital stay.  This serves as an adjunct to the hospital record noted in section one.

Step 6 – Chronic Disease

     When your health breaks down and chronic disease sets in, managing disease is vital to maintaining function.  Partnering with your doctor to manage chronic disease decreases its impact.

     All hope is not lost if you become afflicted with a chronic disease.  Proper management has the potential to limit its negative effect on your health and function, but it requires that you take health care responsibility. 

       Personal health care responsibility can have a significant impact on the treatment of chronic disease.  Health care responsibility takes many forms including exercise, good nutrition, avoiding tobacco and tracking health care. 

     Management of chronic disease is a partnership between you and your health care provider.  Chronic disease is managed with healthy lifestyle, disease monitoring, and healthcare screenings.  Working with your doctor is vital to assure disease is managed and disability and death are limited. 

     When diagnosed with a new disease or condition, do not assume your doctor will take full responsibility in managing it.   You are one who has to live with the disease and its impact and you need to take responsibility for managing the disease. 

     The doctor is still very much involved but he or she cannot do an adequate job without help from you.  Your doctor is like a wide receiver, and you are like the quarter back.  Having a good wide receiver can get you a lot of touchdowns, but if the quarterback never gets him the ball he will never score.  If you do not get the information to your doctor he or she will never be able to help you.  Great quarterbacks can make average receivers look really good.

     Section six is a place for you to record information on chronic diseases.  This is place to store literature on the chronic diseases that afflict you. 

     Speak with your doctor about any information that he or she desires for you to collect.   Check out the book Chronic Disease Guide: How to Prevent and Treat Common Chronic Diseases for more information on chronic disease.   

Children’s record

     The children’s health record is similar to the adults, but the information is slightly different.

• Fill in your name, date of birth, address, phone number and gender.
• Report the blood and Rh type

• What is your religious background?  For example, Catholic, Hindu, Jehovah Witness, Muslim, Protestant etc

• Report your ethnic background on your mother and father’s side if known. For example, Mother – Hispanic/American and Father Asian/American.
• Record demographic information for the mother and the father of the patient
• Record information about the birth as outlined on the form
• Record two emergency contacts.  This may be the mother and the father or someone else if appropriate
• Record the names and contact information of the child’s doctors including the primary doctor and any specialists
• Record information on the patient’s insurance
• Record information on the patient’s diseases including any medical and infectious diseases. 
• Record family history information.  For any parent or sibling record the date of birth, age at death (if applicable) and any diseases that afflict that individual and the date they were diagnosed.  Record if any person was or is a smoker. 
• On worksheet 2, record information about doctor visits, vision appointments and dental evaluations.
• Record information about hospitalizations, any surgeries or device placement (pacemakers, insulin pumps etc.) as well as any information about laboratory evaluations, diagnostic tests or procedures. 
• Record information on growth and development.  This will include information about the patient’s age, height and weight. In addition, record the age in years and months that the specific landmarks on worksheet 3 are achieved.  
• Record dates of immunizations on worksheet 4.

Step 2 – See information under the adult section for step 2 and complete worksheet number 5 of the children’s personal medical record. 

Steps 3 through 6 – See information under the adult section for steps 3-6. 

Summary

      The medical system is a complex, fragmented system.  It falls upon the shoulder of each individual to take responsibility to assure proper health care, which can result in more effective care.  Keeping your personal health updated will help you understand your medical care and make you a partner in your medical care. 

     Implementing the personal health care system results in significant improvements in your health.  This helps you communicate effectively in the health care system and prevents you from slipping through the cracks.  The payoffs of being an active member of your health care will be immense.