Have you visited a new doctor lately, or took a trip to the ER? How long did it take to fill out those long patient history forms? Could you remember when you had your tonsils out? Or whether it was a relative on your mother's side that had diabetes or on your father's side?
Just think how much more difficult it is for an older adult to remember past surgeries and if they had measles, mumps, or both? If your parent has vision or hearing problems, so you really want to ask them questions in a quiet waiting room about personal problems, like their last menstrual cycle or a man's prostrate or ED problems?
The answer is to write a complete personal medical history, including current problems and medication, and have it available for each doctor's visit. Having all the information at your fingertips is especially important in an emergency situation or when your loved one is too ill or infirmed to answer questions.
About six years ago, I started gathering the information and writing medical histories fro each member of our family and for some of our older friends. As people grow older, they tend to need more medical care and visit more specialists. It's great to fill out only the name, address, insurance pages of the big stack of forms and write "See attached medical history" on all the others.
I have included instructions for writing a personal medical history. (Medical History Example in the sidebar) I've listed the primary topics you should include, like allergies, medications, and continuing medical conditions, with examples of the kinds of things you might put in each section.
Next to allergies, the medication section is the most important, and useful. For the emergency room or a new doctor, knowing what medicines a patient is taking will affect treatment. For example, if you have diabetes or a latex allergy, or if you are on a blood thinner, the doctor will know what you can or cannot have in the way of treatment for an injury or illness.
For regular appointments with your doctor, take your history with you. At home, mark any prescriptions you need to refill or need to ask about. Have it handy as you talk to the doctor, so he or she can easily see what you are taking, how much, and how often. Cross off any medicines that are discontinued, and write in any changes to the dosage. If the doctor adds anything new, write it down on your history as he says it, so you know you have the dose and frequency correct. This is also a good time to ask about any drug interactions or cautions, like taking the medicine with meals or do not take alcohol, cheese, or grapefruit while taking the medicine.
When you get home, update the file in your computer (using Save As with the current date as part of the title) and print a new copy for reference. (Be sure to keep the old versions of your history. You never know when you might have to look up a date or a type of medication you took a year ago.)
The history I wrote for my father was priceless to me as his Alzheimer's progressed. When my mother cut her leg badly and we had to call an ambulance, I got her settled with a large towel around the cut and hit the button on the computer to print copies of her history as I was talking to the 911 operator. I had one ready for the paramedics so I could concentrate on her and not on answering questions.
I gave another copy to the ER doctor. She was shocked at having everything she needed to know in one place, clearly organized. She said it saved her a lot of time in determining what medications to prescribe and what not to do. In mom's case, she doesn't take blood thinners, but she is allergic to penicillin and latex, all of which was important in her emergency care. The doctor came to find me later and thank me for having the information written up. She said so many patients come in with no idea what they are taking or the dose. Some can only vaguely remember that their doctor gave them a little white pill or a big yellow on, and they aren't sure what it was for. If someone is in great pain, or unconscious, a doctor needs to know if they have a history of seizures or a pacemaker. If you are caring for a family member, you need to know all you can about their medical conditions.
Think about preparing a medical history for yourself and your loved ones. I've actually had people pay me up to $50 to help them gather their information and get it organized. It's that important.
NOTE: This is also a good time to go through the medicine cabinet, clearing out old, outdated prescriptions, and determining what the person is actually taking, or what they should be taking but aren't. A friend had diuretics prescribed from three different doctors over a period of time, and had continued each one. By checking the prescriptions she was taking, we discovered the duplication and it answered a question about her health and weakness. Her doctor selected the right one and canceled the others.
To help someone put together their medical history information, go through the questions on the example, filling in everything they know easily. Then give them a list of things they need to look up, ask relatives, etc. After a day or two, go back and finish the history with the information they gathered. It may take a little time to set it up in the first place, but the results and security of having the right information on hand in an emergency is well worth it.
Click on Medical History Example in the side bar for more information.
Take care,
Kathy Frost
Through our interactive, HIPAA compliant website we provide a communications hub for everyone on the caregiving team by organizing and storing essential daily records. We connect family, friends, and healthcare providers for the best possible care and quality of life of a loved one.
http://MeAndMyCaregivers.com
Posted by: RebeccaColmer | July 07, 2008 at 10:51 AM