Record time: Organizing medical paperwork

No one knows your medical history better than you do. If you want to play an active role in your care you’ll find it helpful to organize your own personal medical information. You probably receive care in more than one place, or from more than one health care provider, meaning that your records are in many different locations. Keeping your personal medical information in one place can save time and confusion.

There is an interest in establishing a national electronic medical record system in the United States, but this is controversial. This is likely to be several years down the road, you need to organize your own records for now.

There is no “one size fits all” way to organize your health information. Some clinics, support organizations and patient guidebooks provide notebooks or outlines of systems that you can use to keep your records, and there are some computerized systems.  Your system should be easy to add to regularly.

If you maintain paper records, consider using a binder where you can easily add new sections or new pages. If keeping your own records is too difficult, ask a family member or friend to help. Here are four kinds of personal medical information to be able to get to easily.

Calendar or appointment book

If you use an appointment book or have a personal electronic device with a calendar, take it with you to each health care visit. You can use it to anticipate when you will be feeling at your best (or worst), so that you can plan your activities. Unfortunately, life with illness can be unpredictable and things can change for many reasons, so be prepared to be able to change the information that you have entered.

Medication list

It is important to bring a list of all of your medications to each of your medical appointments. This list should include over-the-counter medications and any dietary supplements or botanicals you take.You may have several health care providers and they will all want to know what medications you are taking.

You can include an area on the list to “check-off”, or “flag”, prescriptions that need to be refilled soon. If you maintain a list over time it will also help you remember whether you have taken a medication before. Since the names of medications can be hard to remember, this written record can be very helpful. If you can, include the following information.

1.    Name of each medication
2.    Dosage of each medication
3.    How often you take each medication
4.    When you started taking them
5.    If you have stopped taking it, when you stopped
6.    What the medication is for
7.    How you respond to the medicine, including side effects

 

Health care providers

Keep the names and telephone numbers of your health care providers. At your primary care provider’s office, ask for the name of the nurse or physician assistant who works with them, as they are often more available to answer questions. Administrative or support staff in the office can also help you get the care and resources you need; learn their names and how to reach them.

Your medical history

You may think that you will never forget the details of a medical experience, but time has a way of blurring the memory. The detail you keep in your records will depend on the time you have and your specific needs. Include the date; your diagnoses and treatments; hospitalizations; specialist appointments; diagnostic tests; and surgical procedures.

Start each entry with a date, so you can remember years later when events occurred. Keep some information, such as names of providers, medications, and insurance numbers that you need often with you when you go to appointments.

Your personal health record is an important way for you to participate actively in your medical care. It will help you feel more in control, and remove doubts about details. Once you get into the habit of maintaining your own records, it is easy to continue.

References

Pain Resource Guide: Getting the Help You Need. American Pain Foundation. (2009). Retrieved November 14, 2011 from http://www.painfoundation.org.