Recording Your Health History
Do you know the last time you had a tetanus shot? Or all the doctors you've seen in the past five years?
It's easy to lose track of shots and tests you've had, doctors you've seen, and illnesses you've been treated for. But there's also an easy solution - write it down!
Writing down important health information is the best way to remember it all and have it ready when you need it, especially during a medical emergency.
Taking Charge of Your Health
Keeping a written health history can improve the health care you get and help you stay well. It serves as a memory device and a prevention and communication tool. You can use it to remind yourself and your doctor
- when it's time for a screening or a test,
- who in your family had which illnesses or diseases that could put you at risk,
- when symptoms for different illnesses began, got worse or better, and ended.
A health record also helps people with chronic illnesses manage their conditions better by tracking flare-ups and their possible causes. For instance, noting when you began a new medication could explain a sudden spike in blood pressure.
Many people think of a "medical record" as something that only a doctor or nurse handles. In fact, more and more people are appreciating the value of a "personal medical record" that allows patients to track their own health and health care. According to AARP Visiting Scholar and Geriatrician Dr. Bill Thomas, keeping this kind of written record is one of the most important steps that patients can take to improve the safety and quality of the health care they receive. "Nowadays," Dr. Thomas says, "patients are partners with their doctors and things work best when both partners are involved with the task of keeping accurate records. A personal medical record can be a real life saver."
Having a record of your health is especially handy when you have limited time during a doctor visit. Information your doctor might need to diagnose and treat you will be at your fingertips. Knowing which tests and treatments you've already had will prevent the doctor from repeating them.
Keeping your own medical record will remind you about questions to ask and information you should give to your doctor, such as when you had your last mammogram or tetanus shot.
Having your own records is helpful if you travel or switch doctors and your office medical records get lost or don't follow you to the new office.
Times Have Changed
"We no longer have family doctors who know our entire family history and have treated us since birth," says Karolina Kawiaka, an architect and professor at Dartmouth College who created a lifetime health journal as a baby gift for friends. "Having our medical histories conveniently in one place could help spot important trends in our medical conditions that could be life-threatening."
Kawiaka got the idea to create the journal from her own health records, which were handed down by her mother, a registered nurse. Not only were they the most valuable thing she owned, "they got more valuable over time, especially after I had children."
Kawiaka was "stunned" to learn that more people don't document their health care information, often keeping better records on their pets and cars than they do on themselves. Having all your health information available "makes a huge difference in the care you receive and in the whole doctor/patient relationship," she says. "Being organized saves everyone time and effort."
What to Include
You don't have to be an organization freak to keep health records. Nor do you need to spend countless hours of your time. At a minimum, you can use charts or blank pages in a journal or notebook to record:
- personal identification, including name, birth date, and blood type
- doctor visits and date of last physical
- dates and results of tests, procedures, or health screenings
- any major illnesses or surgeries you've had and when
- a list of all the medications you take, the dosages, and how long you've been taking them.
Other Information to Write Down
- any chronic conditions you have
- all allergies, including drug and food allergies
- the names of your pharmacist and all your doctors, with their addresses and telephone numbers
- birth date and blood type
- family history of illnesses, such as cancer, heart disease, diabetes, and mental illness
- the name and phone number of an emergency contact and/or caregiver
- the name, policy number, address, and telephone number of your health insurance company
- whether you have an advance directive or living will
- organ donor authorization
- opinions and correspondence from specialists and providers
- eye and dental records
- permission forms for release of information, operations and other medical procedures
- history of any counseling received
- lifestyle habits: smoking, drinking, sleep, exercise, eating (how much, how often)
If you are technologically savvy and are interested in keeping your records electronically, you have some options. Portable devices are available that allow you to carry the information on a USB that plugs into computers with USB ports. Additionally, Internet-based services offer secure servers that you access from your computer and on which you enter your information. Some of these are free; for others you may have to pay a fee or subscription. If you do use an online service, double check that no one else will be able to access your personal information. Also, be sure you know how you can permanently and completely remove your information.
Journaling
Those who want to record a more thorough health history can try journaling. People use journaling in different ways. For instance, you can keep a journal to record emotions, allergic reactions, eating, exercise, and sleep habits. A health record journal allows you to record not just illnesses or blood pressure readings, but questions for your doctor and how you were feeling or what was going on in your life at a given time.
This kind of journaling provides a more holistic or complete approach to health care, according to Kawiaka. It helps you spot trends and take a broader overall look at your health. For example, if you're depressed, you might stop exercising or have physical health problems you hadn't experienced before. "When you think of your health, you're not just a cholesterol number or blood pressure number," she says.
If you're new to recording your health information, start out with the basics and build from there. It's never too late to start. And the next time you're desperately trying to remember when you had your last physical, you'll be glad you did!
AARP Resources
My Personal Medication Record
This record will help you list all the medicines, including prescriptions, over-the-counter drugs, dietary supplements, the doses and how they are taken.
How to Talk to Your Doctor
Keeping good health records can improve communication with your
doctor and result in better care.
Stay Healthy, Practice Prevention
Working with your doctor to stay healthy is as important as
getting the right treatment when you're sick.
Valuable Documents at Your Fingertips
Knowing where to locate the family’s important documents is a big help to adult children who may need to step in during an emergency.
Additional Resources
American Health Information Management Association
Guidelines for starting your own personal health record.
Personal Medical Records
The latest news, overviews, health check tools, privacy and confidentiality information and links to organizations.
Books
Find these books online at www.barnesandnoble.com.
Healthwise: Personal Medical Record and Disease Prevention Guide
Kim Hendrickson Leffler, Basic Health Publications, 2004
Simply Essential Family Records Kit
Liberty Craig, Self-Council Press Inc., 2001
