Medical records are one of those things that people always find reasons to avoid like the plague.
If they are healthy, then it’s assumed that you don’t need a medical record. If you have a chronic health problem, it can feel overwhelming to know where to start.
A medical record is something that every person should have, no matter your health history. If you’re healthy, you should still have a basic record that outlines what immunizations you had as a kid, any surgical procedures (including cosmetic ones) and any periodic vaccines (like a pneumonia shot, which is usually every 5 years). At the very least, this helps you keep track of which immunizations you might need in the future. As your parents age, a record can help both and you navigate the new doctors they might need and keep track of preventive screenings that are a part of the aging process. Having trouble remembering if it was James or Sally that had the chickenpox 3 years ago? If you have a family, then records are essential. If, like me, you have kidney damage (or a pace maker, etc.) then having a record can save your life, by alerting doctors, technicians and emergency personnel that specials measures might be needed – or avoided – in your care.
Need more convincing? Here are three more ways a medical record can help better your health care:
- Keep track of medications, herbal remedies, vitamins and other treatments to prevent dangerous reactions. Even perfectly healthy people can experience potentially dangerous reactions through the mixing of over-the-counter medications, herbal supplements and other types of treatments. By keeping a record of all your medications, even something as simple as aspirin and vitamins, you can help your doctor and/or emergency staff quickly pin down the source of any sudden health problems.
- Keep your doctors on the same page. How often have you had to wait days or weeks to get one doctor to send a blood test result or some other record to another doctor? Coordinating information between several doctors can be a frustrating experience. Smooth the process a bit, by taking notes during a visit to pass on to your other doctors. Another step is to request copies of your lab results and simply pass these copies along to the rest of your health network. Keeping a copy for yourself can save the time and hassle of waiting for the office to send it out.
- Your doctor’s records might not tell the whole story. Let’s face it; most people don’t run to their doctor for every little thing. There was one winter when I was routinely waking up with a fever. After one or two trips to the ER, I just popped a few aspirin and went about my day. Sometimes you don’t tell your doctor everything – you might have forgotten a detail about a symptom or feel that it’s too embarrassing to speak about. Your doctor isn’t with you 24 hours a day, so it’s silly to believe that your doctor’s record tells everything about your condition. Keeping your own notes can mean the difference between a quicker diagnosis and more accurate treatment. Lupus, like many chronic illnesses, has many symptoms and many can appear to be other diseases (for example, I was treated for juvenile arthritis for years before they even thought to test me for lupus). A symptom that only appears “sometimes” might make all the difference.
How to Start Now
There are tons of ways to start keeping a medical record without feeling overwhelmed. You can start with something as simple as writing your current doctors’ contact information and your current medications inside any old notebook and go from there, making notes every time you feel the need. You can alter a day planner or get a 3-ring binder and create separate sections for past surgeries or symptoms or create a time line by making sections for different years. If you have copies of old lab results, organize them into an accordion folder for easy future reference. Even though any old notebook will do the job, it might be easier to look for something that you can add pages to in the future, or reorganize as you need.
Want a more high-tech solution? There are lots of options available for every device you can think of. A basic PIM (Personal Information Manager) is a good place to start and many programs can be adapted for medical use without too much trouble. There are also many websites now offering web-based medical records, that can be accessed from any computer. Features vary widely with some offering mobile versions for phone access, email reminders for medications and appointments, file-sharing options to share information with your doctors and even printable cards that give emergency responders access to your information. There are phone apps and stand-alone programs available as well.
The American Health Information Management Association (AHIMA) has a website called MyPHR.com that offers a great overview on electronic health records, why they’re helpful, and how to start your own. They even have a search engine that will give you a list of programs to look at. It’s a small selection so far and by no means covers all the options out there, but it’s a great starting place.
Whether you’re thinking of going old-school with a written record, or considering a program here are a few quick tips to take the worry out of starting your medical record:
- What are your needs? Do you just want a place to record daily symptoms, or do you want to create as complete a record as possible? Speak to your doctor also about what information they would like more of (weight changes for example, or how often a symptom appears). This will help you sort through the features of various programs and apps to find the ones that you’ll actually use.
- Keep it simple. In my experience, the more bells and whistles something has, often the more stressful it is to learn how it all works. The longer you spend mucking about with features, the less time you’ll likely spend actually using your record, so aim for something that you can just dive into.
- Don’t expect to complete a whole record at once. Better to break it down into chunks and keep in mind that this will be a continuous work in progress.
- Try to make it fun. Your record doesn’t have to be bland or depressing. Paste in inspirational quotes or images. Add a few comics that make you laugh. Look for a planner in your favorite color or style.
What other tips do you have for starting a medical record?
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