“Professional Patient Tip” Get Organized! Your Personal Health Record

 

It is important for every patient to take an active role in their own healthcare. A personal health record is designed to grow as your needs grow or your health changes, and should be updated as often as needed. It is important to record how your health changes and mark your progress.
Take the first step!
Do not get overwhelmed! Take your time, and collect a little bit of information at a time. You will be surprised how it all adds up and you will feel much more organized and prepared when seeing your doctor. Also, once you have gathered and collected the necessary information, you’ll be surprised how easy it can be to organize it and print it out later.


I keep all the following information on my computer in one text document. I revisit it whenever I am going to a new doctor and add or make changes if necessary. It is a great tool to help me remember questions or information when I’m at the appointment, and many times I can skip filling out paperwork concerning my health history that would otherwise be tough on my arthritic hands.
Your personal health record should include the following information:
Patient Information
This information includes your name, address, phone number, and date of birth in addition to:
· Emergency contact information
· Current health insurance information (Group Number, ID Number, etc)
· Doctors you are currently seeing, and your reason for seeing them
· If you were referred by another doctor, the referring doctor’s name and contact information
 

Lifestyle
Record your lifestyle behaviors such as tobacco and alcohol use, exercise, and eating habits. Note any significant stress or sleep changes.
 

Current and Past Medications Record
Maintain an accurate record of your medications to help you save time and communicate more effectively with your healthcare provider. Be honest with your doctor about when and how you are taking your medications.
· Include the name of medication, current dosage, and frequency.
· Do you forget to take your medications?
· Are you or have you experienced any side effects? (ie. dizziness, nausea, fatigue)
· List alternative treatments you receive (chiropractic, massage, acupuncture, etc.)
· List all known allergies
 

Questions and concerns for the next visit
Leave a place for notes and questions that you may gather between visits. It is so easy for us to forget what we want to ask our doctors, or find words to explain an odd symptom or side effect when we only have a few minutes to speak with the doctor. If you have your questions listed along with he rest of your important information, you will not forget them and will use your time with the doctor more effectively.
 

Additional Information worth including

_______________________________________________
The following information is good to have available to you for own reference, even if you are not bringing it to every doctor appointment.

 
Medical History
Record your allergies, immunizations, treatments, vital signs, laboratory test results, and preventive screening tests and results.
 

Family History
Store information about your immediate family medical history and their health risk factors.

Reports
Try to get copies of your personal health records from past doctors. If possible include test results x-rays, etc. If you can’t keep this information on a computer, store it in a folder in a safe place with your other important documents.
Although this might seem like a lot of information to gather, once you have it collected it will be easy to update. Try to make a habit of making notes or changes immediately following doctors appointments so you don’t find yourself trying to remember those questions you had for the doctor right before your appointment.
Having this information available is also good if you ever need to apply for disability or fill out insurance claims. Don’t rush, and don’t expect to have your personal health record completed in one session. If you take your time, and work at your own pace, you’ll certainly be rewarded the next time you are handed a clipboard, in an unfamiliar waiting room, and you are asked to provide the very same information you’ve prepared in advance.
Written by Christine Miserandino

©2024butyoudontlooksick.com

  • Thanks for the tips. I have Parkinson’s and for me to write in a form when I am under just the slightest bit of stress is impossible for me. I have my medications on a computerized print out but now that you mention it I should do more. I am also from Long Island I live in California now but I grew up in Islip.

  • Sapphire

    Some great ideas! I keep probably 7 sheets of paper folded up in my purse with current meds (including allergies, contraindications and hx of stroke), psych med hx, docs, including addresses and phone numbers, anesthesia and surgical history (I don’t respond well to anesthesia, even the one they “swear” won’t cause sickness)… I can’t remember what else. I admit they were a bit of a pain in the rear to gather (so as was stated, a good project over time), but now the updates are a cinch. My current meds are broken down by medical, psych and fibro/migraine and then I have a column for prn with *** to indicate which are. Oh, yes, I am just a little OCD. LOL

    I love putting “see attached” in those spaces at new docs and given the bulk of information (it’s SO much easier!). I think they like it, too. I print out a copy for them and they’ll ask “is this for me or do I have to make a copy?” Some of them even smile when I say it’s for them and I get some pretty shocked thank yous. It’s all in my purse with my address book and insurance cards, but I wonder if I ought to include that info on my papers, too?

    Great article!

  • Marie

    Thank you for this! I have kept my medication list typed up in my wallet and on my fridge for years now due to my medical conditions (Endometriosis, Fibromyalgia, Chronic Migraines and Osteoarthritis). The multiple conditions create a need for a combination of meds that can be confusing to myself, much less anyone else! I fill my daily pill minders once a month (I have 4) and keep them in the same place at all times so that it is easy for my family to tell if I have taken my most recent dose. I am careful to update my medication list after every doctors appt as well. My father, brother and closest neighbor all have my med list emailed to them for my safety…if something happens to me and I am taken by ambulance, they are able to hand a copy to the EMT or fill in the doc with the latest info. This may seem a little extreme to some that do not have multiple medical conditions or take multiple meds, but these precautions can make a big difference! Many of my meds do not interact well with others, and I do have potentially fatal allergies to others.

  • Raquel

    It is also good to have it readily available for your family and/or caregiver. Even if you don’t have a constant caregiver, if something was to happen and require a visit to an ER, this type of information should be readily available.

  • Jacquie K.

    Christine, thank you for this awesome reminder. Two to three years ago I prepared my “Medical Resume.” Currently, after 29 procedures to date, it’s a 7-page Word document that I update whenever anything changes. Before any doctor appts., I print out 2 copies. One I staple together; the other one I leave loose. I have found some doctors want it one way and others don’t. Also, the doc & I each have a copy and can go over it together. Remember to put, at least, your name, the date, & a page number on each page. When I save the document, I date the newest file name in my computer to the date of the change. Then, I have the older ones saved for reference.

    You didn’t mention also listing any OTC (over the counter) meds you take along with any vitamins and/or supplements. Doctors appreciate having this information, also. Additionally, you gave me the idea to include emergency contacts and their information. Now, you know how it got to be so long! I keep adding more and more info!

    Thanks for all you do for us fellow sufferers here in BYDLS-land!

  • Madelyn

    I’ve been keeping my medical records including current meds & treatments, prior meds & treatments, problems with meds, past and present diagnoses with dates, contact info on all docs & other practitioners I’ve seen, and a health diary in Word docs for a few years (in my case for chronic migraines, chronic headaches, and chronic depression). Once the files are set up they’re so easy to keep updated. Docs have *always* been appreciative of this information overload, as it’s far easier to read over than to try to remember every little thing when under the stress of being in a brightly-lit doctor’s office. And my records came in quite handy when filing for SSDI.

  • Laura

    Thank you for the information.
    My sister and I keep our information on the Medic Tag. It is a usb drive that can go with you easily and anytime. Another reason we like it is that you can print information when needed.

  • *Deena

    Like Maureen, I keep track of my allergies, and keep a copy in my wallet as well as on the computer. My single sheet of paper has lists my current doctors’ names and numbers, my diagnoses, my current medications and dosages, my supplements, and my allergies. I carry this around not only for the doctors, and yes, I also take them their own copies, but also for possible emergency medical personnel. If I’m in an accident or pass out somewhere, I want the paramedics to know what I’m already on before they start administering more medications! And in an emergency room, I want the doctors to know what’s wrong with me, that I’m allergic to several antibiotics, and what medications I’m already taking. Medical records are important in multiple situations. Thanks for reminding all of us!

  • Lucy Smith

    I’ve been keeping records similar to your recommendations ever since my health conditions become more complicated. The Medical professionals ar always been very appreciative of the info.
    The records have also proved invaluable to me at times – fibro fog can sometimes make me forget my own name!! LOL!
    Thank you for the tips and advice – I’ve now updated my records with even more useful information.

  • Ann

    This is really helpful information. I used to keep med. records in a notebook, now it’s a couple of boxes but sometimes it’s really important to have older records & it may be difficult to obtain them after a number of years. Our local hospital will give me copies of any tests done when I present them with a written request. Keeping these records: gives me quick & easy access if/when I go to a new Dr. Dr.’s retire, patients move, Dr.’s call in experts. Each time there is a need for old records.
    A patient information sheet is really helpful to have. Mine includes the names of my Dr.’s: G.P., Cardiologist, Nephrologist & Dentist, along with their office address’ & office phone numbers. It’s a quick reference for a hospital or a new Dr. or urgent care… if needed.

  • I have a lot of allergies and also need stress doses of hydrocortisone due to an adernal insufficiency. I carry a types sheet in my wallet and I always bring one to a new doctor’s office, so when I have to fill out the allergy area, I have it all printed out neatly. I also have my contact info on top and all my current medications and doses on the bottom. I keep it in a word processing file, so I can update it as necessary. i can’t tell you how happy the staff and doctor’s are with this, they can read it, and they don’t even have to make a photocopy because I bring them their own. It saves me trying to remember, and also a lot of writing on those forms when I don’t feel well.
    Thanks for the great tips about assembling your medical history, I need to get better at keeping that current and this is a good way to start, a little at a time.

  • Mary Henderson

    I request alll my medical records once a year from every doctor then go through it and organize all my paper work into a binder under the doctors name. I have fibromyalgia so I see a lot of different doctors.

  • Heather

    May I also suggest keeping the names & phone numbers of previous doctors on the list even after you have stopped seeing them? If you move or have to complete a release of records at a new doctor it is nice to have that information available.
    Having worked in the medical field as a records clerk, I can’t tell you how much I loved the patients that had that information readily available (some even had the fax numbers for me).

  • Maureen

    Great recommendations Christine! What I have had to do is use my personal journal and bring that to my appointments for prompting me to ask my questions and provide recent updates. I have also used that to take notes in. But your ideas will help to organize my health records, questions, updates, etc. Thank you!