Managing Your Health: Your Own Records

"When was your last surgery?" "What are the names of your medications?" "When was your last blood test or tetanus shot?" Most of us have heard these questions when we have visited a new doctor, when we have been in an emergency room or when we have been admitted to a hospital. Especially at these times, it is difficult to remember the answers to so many questions. Those of us with long medical histories may not remember the dates or the years of immunizations or hospitalizations, etc. We may rely upon the memory of a family member or friend. There may be a delay in treatment while medical records are gathered, or while doctors confer. Some simple organization ensures that important information is at hand when you need it. Here are some suggestions:

One good system is to purchase a 3-ring binder with dividers and pockets. On the first page, have your name, address, phone number, date of birth and next of kin, your primary care physician's name, address and phone number(s) as well as the same information for any physicians you see regularly. Next, write any conditions for which you are being treated and any medications you take regularly, including over-the-counter medicines. Then list any illnesses, surgeries, broken bones you may have had and the year in which they occurred, and if you are a woman, if you have had any pregnancies. Note anything like blood transfusions, hip or knee replacements, or organ transplants. Follow this with your significant family history: parents alive or deceased, and if deceased, cause of death; how many brothers and sisters you have/had; and any illnesses each may have had. You can organize sections of your notebook, like: history and medications; hospital discharge summaries; lab and x-ray reports, etc. Use sections that work best for you.

If you have had surgery, you can request a copy of the pathology report from your doctor to keep in your folder, as well as a copy of any hospital discharge summaries and your most current lab or x-ray reports. You can request copies of any consultations you may have had with doctors and keep them in your folder. Someone close to you should know where you keep your folder, in case of emergency. In fact, it is a good idea to keep a list of your medical conditions and medications along with your doctor's name and contact information in your wallet or purse at all times. In an emergency, this is the best time-saver.

Most of us do not dwell on our medical histories. That's one reason why we have difficulty recalling dates, illnesses and procedures. A prepared and up-to-date medical notebook takes the stress out of remembering all of the details, enabling easy and quick access to all of your pertinent information. You may want to include a checklist of items to bring to the doctor/hospital: notebook, insurance cards, a list of questions you may have for the doctor, as well as blank paper and a pen to take notes. You will feel more in control and will be a better partner in your health care team with this simple tool.