Precious Medical History

Gone are the days when  people kept  their family physician past childhood through young adulthood and  parenthood and  into old age.

Now most  health care consists of an assortment of primary care physicians and  specialists, supplemented by visits to urgent care clinics and  emergency rooms. Unfortunately, that patchwork of health care often  comes with a disorganized collection of medical records, to the point where  it’s unlikely that any one doctor knows  a patient’s entire health history.

That  means it’s up to you to provide that history. And, no, you don’t have to track  down your old pediatrician; he or she probably doesn’t even have your paper records anymore.

If your doctor is one of the many who have switched to keeping patients’ records digitally, the task of compiling your history will be easier.  There are two kinds of digital records: electronic medical records and electronic health records. An EMR is a digital version  of the records individual doctors keep— it’s like your doctor’s old medical chart, but now on a computer. EHRs are designed to help share information among different doctors and hospi- tals—and with patients, too.

Since January 1, 2014, all public  and private health care providers have been required to adopt and demonstrate “meaningful use” of EMRs  in order to maintain their Medicaid and Medicare reimbursement levels. There were additional incentives for health care providers who adopted EHRs.

There are clear benefits to electronic record keeping. Besides eliminating the headache of paper files and making it easier to share information, digital records may save lives, explains Lesley Kadlec of the American Health Information Management Association. Emergency room  doctors no longer  have to waste time dashing to the records department for the chart of a patient who was just admitted—they can simply call it up on a computer screen.

There are stumbling blocks, however. For starters, because EHRs are a recent phenomenon, everyone has a medical history of appointments and  treatments that occurred before digital records existed. It’s also surpris- ingly difficult,  given the ease with which  other information is shared online, to swap records between your primary care doctor and  a specialist’s office if they don’t use the same EHR  system. Compiling your history may still mean contacting many different providers.

Here’s what you need to have in your possession and how to find it.

1/ A list of all current meds

Keep a list of what  you’ve been prescribed plus anything else you’re taking, says Lynne  Lillie, a family physician in Rochester, MN. “It’s important for a doctor to know everything a patient is taking,” she says, including vitamins and  supplements - many can interact with prescription drugs.

If you see different doctors who prescribe meds  without consulting each other (and don’t share an EHR system), they can refer to your list before  making any new drug  recommendations, says Navya Mysore, a primary care physician with One Medical in New York City.

WHERE TO GET IT: Start by writing down, typing up, or photographing the labels
of your current prescription meds, including drug name, dosage, and instructions. Contact the prescribing doctor for any missing information. Then  add to the list any vitamins, supplements, and other diet, nutrition, or weight  loss aids you take.

2/ A description of your chronic medical conditions

If you’ve had care for an ongoing health problem such as asthma or diabetes, you’ve likely tried several treatments. It’s helpful for your doctor if you keep track  of what you’ve already tried, what’s worked or hasn’t worked, and what kind of progress you’re making.

WHERE  TO GET IT: If you received your diagnosis within the past  7 to 10 years, those  paper records may still be avail- able. But if your diagnosis was made before  that, your doctor may have discarded them. In these  cases, do your best to recall the earliest stages  of your condition and  treatment and  write down  what  happened. Consult other doctors who have treated you since then to obtain your records.

3/ A log of past procedures

Making sure your physician under- stands what  kinds of medical proce- dures you’ve had in the past can affect your future treatment. If you had a mastectomy, for example, your doctor will tailor  ongoing breast cancer screening to your personal history. If you’ve had several cancerous moles removed, a doctor will want  to keep a close eye on other suspicious spots. Include outpatient and in-office proce- dures in your log.

WHERE TO GET IT: You probably remember big surgeries and procedures, but if you’re unsure, consult the insurance companies you’ve used. They should be able to provide you with a list of the treatments and procedures doctors billed them for over the period you were covered,  says Dan Greden, head  of e-health products and clinical innovation for Aetna.

4/ A copy of recent test results

The results of cholesterol, blood sugar, and blood pressure tests provide a base- line for any doctor to get quick insight into your overall health, Mysore says. If you’re being followed  for specific conditions that require frequent work- ups, such as anemia or hypothyroidism, include those  numbers, too, as well as results from regular screenings like Pap tests and mammograms.

WHERE TO GET IT: Request a copy of the past 2 years’ blood work and screening results from your most recent physician.

5/ A list of immunizations

“A lot of patients have no idea what vaccinations they’ve had,” Mysore says. “For certain vaccines,  we can run  a blood test to see if they’ve been  immunized.”

WHERE TO GET IT: Contact your past physicians to see what’s on record.

6/ Your family history

Your family medical history can play a big role in indicating whether you should undergo early screening tests  for conditions such as heart disease, diabe- tes, elevated cholesterol, and  cancers of the breast, colon, or prostate, Lillie says.

WHERE TO GET IT: Talk to family members about their past health problems. It’s not always a cheery conversation, but it could save your life.

Source: Prevention Magazine January 2018

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