The Medical Care Team Benefits from Patient Record-Keeping

The easiest and most effective way for a patient to improve the quality of his or her medical care is to carry a current medical summary to every medical office visit or laboratory.

Patients underestimate how much they can help with their own care. Today's complex medical treatments require full patient participation to avoid overlooking details. Success requires a team approach which must include the patient as well as various medical professionals. The patient is a particularly effective team member because he's always in attendance, he has a sense of continuity, and he's highly motivated. He's also the one who must decide health directives and privacy limits.

Preparing a personal medical summary is within the scope of most patients or their proxies. Use a manila folder or looseleaf notebook so documents can be arranged as needed. List the patient's full name, birth date, social security number, address, phone numbers, medical proxy, occupation history, current treating doctors, special health directives, insurance data, medication coverage, and details about any recent hospitalization.

Patients should describe in their own words what's bothering them currently. If complaints are multiple, list them by importance. To avoid missing any details, go over parts of the body in turn, what doctors call a "review of systems". Patients must set their own symptom priorities and not leave them to family or interviewers.

The medical summary should include all important medical events in the order in which they occurred. Like a good newspaper article, each event should include "what", "when", "where", "who", "how", "what treatment", and "what results". An event description can be as brief as the following example: "inflamed gall bladder 10/90 found on x-ray and treated by surgery at General Hospital by Dr. Jones".
The family medical history has grown in importance recently because of developments in gene-based treatments. Use the following format to describe the close family: relation, alive or dead at what age, and the diseases present for each one. For example: "father died at age 47 of a heart attack", or "1 of 3 siblings has diabetes".

It's impossible to overstate the importance of a medication history. If nothing else, patients should carry a current medication list with any drug allergies on all medical visits. Drugs are so complex and potent these days that an unfavorable reaction is always a possibility. Keep the medication list separate from the general summary so it can be handed to a pharmacist or a technician without revealing other more sensitive health information.

The patient should record any physical abnormalities in the medical summary. List findings in the order in which they were discovered and include the responsible doctor. Patients should do simple physical checks themselves, like estimating pulse rate and blood pressure for hypertension control.

Add the latest lab test reports to the folder or notebook. Patients are entitled to a copy of any test they undergo. It's usually enough to keep just the latest version of a test and discard prior similar ones. A basic lab test file should include blood tests, an electrocardiogram, a chest x-ray, and a urine specimen report.

It's worth retaining letters from consultants because they often contain important impressions and recommendation. If no letter is available, then record the date, the doctor, and what he found. Also keep billing documents for about 2 years, or longer if they might be controversial.

I'm convinced patients should prepare and carry an up-to-date medical summary because it's the key to success with today's complex medical treatment.

The following list is designed to help you in writing a medical summary.

Preparing a Medical Summary

1. Patient's name (last, first, middle initial)
2. Identification (birth date, social security, clinic number)
3. Full address (street, city, state, zip code, country)
4. Telephones (home, work, cell, pager)
5. Health Proxy (name, relation, telephones)
6. Occupation (current, former, month/year retired)
7. Primary doctor (name, office address, telephone)
8. Consultants (name, specialty, address)
9. Directives (living will, CPR preferences)
10. Insurance data (company, policy type, expiration)
11. Drug coverage. (extent, copays, source of meds)
12. Hospitalizations (what for, where, when, what was done)
13. Current problems (the "chief complaints")
14. Key events (what, when, where, who, treatment, results)
15. Drug allergies (drug name, when, rash or other allergy)
16. Intolerances (drug or activity, reaction, when)
17. Family history (relation, alive, date of death, cause)
18. Prior smoking (in packs per day until what year)
19. Alcohol intake (estimate equivalent drinks per day)
20. Directives (living will, resuscitation, donor)
21. Physical defects (what, what, when, who found it)
22. Height & weight (specify if with clothing)
23. Blood tests (save original reports if available)
24. Latest EKG (ask your doctor for a copy)
25. Chest x-ray (your doctor has to OK its release)
26. Cholesterol (include a full profile if available)
27. Special x-rays (CT scans, MRI's, bone x-rays)
28. Echocardiogram. (all heart patients get this test)
29. Special reports (Holter, stress test, cardiac cath)
30. Consultations (ask your doctor to release these)
31. Treatments (angioplasty, dialysis, physiotherapy)
32. Surgery reports (get reports from your doctor)
33. Device data (pacemaker, artificial valve, prosthetics)
34. Special diet (low salt, low cholesterol, weight loss)
35. Immunizations (type, when, by whom)
36. Current meds (brand, generic, doses, frequency)
37. Active problems (like hypertension, diabetes, CAD)
38. Disabilities (what, when, degree)
39. Doctor’s advice (recent recommendations from doctors)