Your medical history is very important because health care providers use that information as the foundation for medical decisions. Who has more interest in the accuracy of your information than you do?
You might say: writing the medical history is the doctor’s job. You are right. But, have you actually looked at the product of that work? — most people have not. Patients who read the doctor’s version of a medical history are astounded by the number of errors and the amount of missing information. To be fair, health care providers are goal oriented — as they hear the medical history they make diagnoses and once a diagnosis is made the details become less important.
Health care providers absolutely love a new patient that hands them a concise medical history. They love it because:
- They save time
- The information is more accurate and complete than usual
- They can take notes directly on the paper
- It is an aid to write their own version or enter data into a computer
The do-it-yourself (DIY) medical history is great for patients because:
- You don’t need to repeat it on forms, just write “see attached Medical History”
- You can print a copy when you see a new doctor or specialist
- You can take a copy to the emergency room
- You can keep it up to date with a wordprocessor
- You can store it on your computer or “in the cloud”
- Your health care visits can focus on current problems not old records
As helpful as this DIY medical record seems there are some important points:
- The record must be constructed the way health care providers expect — otherwise they will not read it or use it.
- The record must be concise — try to get it on one page (not more than 2 pages)
- You must not omit diagnoses or include any self-made diagnosis
- Avoid duplication — if you include something in one section do not put the same information in another section.
- This is not a test. You can “cheat” by copying from the medical history created by one of your health care providers. After all, it’s your medical history. Make sure you get copies of any “History and Physical” done by your providers.
When you see a new health care provider you should take 2 things:
- A copy of your DIY medical history.
- A small piece of paper with the 3 concerns you want to talk to the provider about
Now, to the nuts and bolts of the DIY medical history. Here are the categories:
- Identifying information: Name, Date of Birth, Address, Phone number
- Past Medical History:
- various diagnoses with dates of any hospitalizations and causes
- recent blood tests, x-rays or other tests with results (or attach report)
- Past Surgical History: name of surgeries with date, surgeon, and hospital
- Childhood illnesses: birth defects or serious illnesses when a child
- Obstetrical History (women): pregnancies and outcome, number of children
- Psychiatric History: depression problems etc. and list of hospitalizations
- Family Medical History: just parents, siblings and children
- Social History:
- where you live, with whom, occupation, when retired etc.
- habits including smoking and alcohol consumption
- advance directives (living will, 5 wishes etc.)
- drug names, strength, how often taken, for what
- pharmacies with phone and fax numbers
- Drug Allergies
- Drug Intolerances or side-effects, what drug and when it happened
- Food or Inhalant allergies
- Immunizations: which vaccines and when
- List of current health care providers: primary care, pediatrician, ob/gyn, and specialists
- Prefered hospital in case hospitalization needed
- Emergency contacts: names, relationship and phone numbers