Health-Care Savvy: How to maintain your own medical records

Health-Care Savvy: How to maintain your own medical records

Your Medical Records: What Experts Advise

From Consumer Reports on Health, 3/96

Did you ever suspect that you once had an allergic reaction to a drug, but couldn''t remember which drug? Or that you already had a lab test your doctor wants to order, but couldn''t recall when? Do you forget the names of medications you''ve taken before or are taking now, or when you had vaccines for a particular disease?

Your doctor may know -- or maybe not. And those missing pieces of information can come back to haunt you -- with needless repeat testing, medication mishaps, even avoidable illness. When it comes to health matters, those who cannot remember the past may indeed be condemned to repeat it. It''s essential to have ready access to your own medical history.

Tracking down lost medical information can be a pain. It may require numerous telephone calls and some time-consuming paperwork. But that''s time well spent. Don''t wait until an urgent problem arises. And don''t rely on your ability to wade through piles of old bills and receipts to fill in the details. Plan ahead. …

How Computers Can Help

  • If you have been hospitalized, ask a copy of the summary report, any surgical and pathology reports when you are discharged.
  • Ask for copies of EKGs, results of any CT scans, MRIs, ultrasounds, exercise stress tests.
  • Keep a list of drug allergies, immunizations, names and dosages of your medications. Note the drugs that did NOT help, and any adverse reactions to medications you''ve taken.
  • Construct a detailed family tree showing key medical facts about your relatives: siblings, parents, aunts, uncles, grandparents. Include date of birth, age at death, major diseases, cause of death.
  • Keep your records all in one place, accessible in emergency.

AMA Recommends Family Health History

The American Medical Association recommends that every family maintain some kind of health history. "Every time we investigate an illness or see a patient for the first time, the family history will guide us as to what direction to take," says Regina M. Benjamin, a member of AMA''s board of trustees. As doctors search for hereditary links for a growing number of diseases, genealogy is playing an ever larger medical role. Information about the deaths and diseases in past generations can be extremely valuable in that research -- and in evaluating your own health risks.

The Medical History as Information Source

From Take Care of Yourself, by Donald M. Vickery and James F. Fries
Addison-Wesley, 1990. (p94)

The doctor has three major sources of information: the medical history, the physical examination, and laboratory tests. Depending on the illness, any one of the three may be the most important. The medical history is the only source of information that is directly controlled by the patient. It is frequently termed "subjective" by doctors because the information cannot be directly verified. To the extent that you provide your doctor with clear, accurate data, you increase the probability of an accurate diagnosis and successful treatment of your problem.

Compiling your family medical history: How important is it?

From Mayo Health O@sis on the Internet

Major illnesses like heart disease, cancer, or diabetes may not always be preventable. But there are important things you can do to reduce your risk and minimize their impact. Mapping your family''s medical history can provide a good place to start as you look at the risks you may face in the years ahead. This can give you the time to develop habits that lead to a healthier life.
(Read the full text at the Mayo Clinic site.)

Getting Access to Your Medical Records may be Limited, Costly, or Impossible

From The Wall Street Journal, 7/31/96

In nearly half of the states, people have no legal right to review or copy their own medical records. But laws vary widely, with some broad loopholes for health providers to deny requests for records. … [T]here are good reasons for people to get a copy of their medical records. They might be moving to another city and want copies to take while they shop for a new doctor. They might want to learn more about a health condition and the treatments they have gotten, or any errors in their records. Doctors or hospitals have policies which determine how easy or difficult it is to get copies of records, and what fees will be levied for research and photocopying. These fees aren''t covered by insurance.

Patient Empowerment
from Cybermedicine, How Computing Empowers Doctors and Patients for Better Health Care

by Warner V. Slack, M.D., Jossey-Bass, 1997

My argument in this book is that computer programs that help patients and doctors with medical matters can both improve the quality and reduce the cost of medical care... Good clinical computing can improve the relationship between the patient and the doctor. (pp xv)

If the computer is to become more ...useful as a patient''s assistant -- helping patients and their families maintain better health, manage medical problems when they occur, seek and use health care facilities in an enlightened manner, and participate as partners with clinicians in medical decisions -- good material must be written and tested. They must then be made available for use both on stand-alone personal computers and on networks such as the Internet. (pp 147)


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