Your Medical History & Preventiuon Guidelines

Preventive health guidelines were developed to improve one’s health using things that prevent disease and detect it early.  They are based on credible research in which the criteria have been studied extensively.  The United States Preventive Services Task Force (USPSTF) is a leading resource for preventive health guidelines along with doctor specialty organizations like the American Academy Of Family Physicians and American Academy of Pediatrics.  There are so many that it can become confusing as to what you should do.  Like one size fails to fit all so do the guidelines. How will you know what you need and when you need it?

Use your medical history as your guide in deciphering through different health organization guidelines.   Though they may address the same thing, there will be similarities and differences.  If you have a history of cancer, you may want to get a mammogram or colonoscopy more often. If there is a family history, you may want to get tests sooner than the guidelines suggest.  Abnormal physical exam findings warrant testing regardless of guidelines.

Be sure to review guidelines from different organizations. This gives you a broader view of what you need.  Look at the pros and cons as they fit you.  Focus on those that concern you and your condition.  Discuss them all with your doctors and healthcare providers to plan your guidelines. Your medical history is your guide to the guidelines right for you.  Best health!

Keep Your Medical Records Current

The best way to find the medical care you need and deserve is to be informed and prepared starting with your complete medical history.  Your medical record is the foundation of your health maintenance.  Collecting your records from your PCP (primary care physician) and each healthcare provider helps you stay current and up to date with your medical care and treatment.  Keeping track of the vast amount of medical information that concerns you is very important.  


A medical release authorization form is required to have your medical records released to you.  Medical record release forms are available through your doctors' offices, hospitals, clinics, and insurance providers.  Many providers have them available on their websites.  Internet searches will bring up medical release forms that can be used anywhere.  Once your form is completed, mail or fax to the healthcare provider. Charges may be incurred for copying and mailing records. 


Electronic health records (EHRs), also called electronic medical records (EMRs), are computerized versions of your medical records.  This format is replacing hard copy medical records. Patients are able to access their records anytime through secure patient portals to look at health provider reports and test results. You can also directly email your doctors, make appointments, get medication refills, and much more.  This can eliminate unnecessary visits and phone calls. 


Once you have obtained your medical records, it is important that you check for accuracy.  If any information is inaccurate, report it immediately to your healthcare providers so it can be corrected.  Make a request to the provider to correct the medical record.  If this fails, submit a statement verifying the mistakes so it can be added to your medical record.  This can prevent future medical errors.


As EHRs become more prevalent, it will be easier to see and access yours on a routine basis.  You will be able to print your records at home.  As you gather your medical record information, keep it in a folder off the computer.  Make a cover sheet listing your medical conditions, medication, allergies/ adverse reactions, operations, family history, social history, and any other pertinent information. This medical summary can then be used on your doctor visits, especially an initial one with a new doctors.  


Help your health care providers provide you with optimal health care.  Keep up with your medical records to enhance and improve your health decisions.  Best health! 

Your Medical Information

One of the first things your doctors and healthcare providers want to know is why you made your appointment. Once you answer this question (hopefully before interruption) there will be questions about your general health and wellness, as well as more information about your reason for the visit. For specific concerns you may be asked:

• How long has this been going on?
• What have you done for it?
• Have you had it before?
• Where does it bother you?
• How often does it occur?
• What makes it better or worse?
• Are there any other symptoms?

You will be asked about how the other parts of the body are working, such as your eyes, ears, heart, breathing, and so on. This is called the “review of systems” (ROS). If there are any problems not related to your main problem, now is the time to let the doctor know.
This will be followed by your past medical history (PMH), which includes:

1. Diseases you have (high blood pressure, sugar diabetes, arthritis, cancer, depression,
   etc.), or have had that are better or gone (including childhood diseases such as
   measles, mumps, and inherited disease)
2. Operations and times you were in the hospital (including accidents)
3. Medication, including prescription, over-the counter (don’t forget about vitamins),
   natural (garlic, aloe), and herbal
4. Allergies and reactions to anything and what it did to you (for example: breaking out in a
   rash, swelling, itching, upset stomach, etc.)
5. Smoking, alcohol, drug use (how much, how often)
6. Shots (childhood, flu, last tetanus, etc.)
7. Sexual (active, using protection, number of partners, diseases)—in females this will also
   include menstrual period, pregnancy, last mammogram, and Pap test
8. Family history (conditions that run in family
   such as cancer, high blood pressure, etc.)
9. Social history—your job or jobs; family; marital status; living arrangement (house,
   apartment, alone, etc.); transportation (drive self, public transport, walk); ambulation
   (use walker, wheelchair); disability (deaf, blind, amputee, etc.); religion, ethnic customs, and traditions

If there is anything left out or that you feel the doctor should know, now is the time to speak up. It is sometimes hard to get someone’s full attention, so take advantage of it while you have it. Some doctors’ offices will have you fill out forms asking the above questions or will ask you the questions and fill out the form for you. This is not a substitute for the doctor’s personal interview and questions.

Writing or typing this information is a sure way to keep all of your PMH http://bit.ly/f8FZ55 . Make a copy for your doctor. While talking you both can refer to this vital source of health information.

Best health!

Making the Most of Your Doctor Visit

When you go to your doctor or health care provider, you should be prepared.  This is one way you can be sure that your doctor visit focuses on your most important health issues. The following suggestions will help you get the most out of your doctor vist.

• Be on time.
• Make a list of things you want to talk to your doctor about. Update the list before each visit. This way you will be able to keep track of what has been discussed, and what needs to be discussed. Try to talk about the most important things first especially those that need immediate attention. Each time you go for your visit, you can refer to your list and take up where you left off. Be sure to express your immediate concerns first. We all know how short a doctor visit can be.
• Make a written or typed medical history* to take with you, especially if this is your first visit to a new doctor. Make a copy for you and your doctor. You both will be able to refer to it as needed. This will save valuable time, and give you and your doctor more time to talk instead of flipping through your medical record. It can be difficult trying to "remember" what test or procedure you had 10 years ago.
• Get copies of your medical records from all your doctors. "The medical record is the cornerstone of keeping track of everything pertaining to your health." You will be able to check the accuracy of your records, and bring any errors or absent information to your doctor's attention. Let your doctor know about anything you do not understand, or if there is something you are unable to read due to legibility. It is surprising to see how many doctors are often unable to read their own handwriting.
• Take advantage of the time your doctor takes looking through your medical chart during your visit by taking your own notes especially questions. As much as 1/3 of your visit time can be consumed by this alone.
• Allow each other to talk without interruption. 
• Bring a trustwothy companion.

Click on "Comments" below to add your tips or ask questions.


*medical history form http://www.mypatienthandbook.com/

How to Get Your Medical Records: Your Life on File

Communicating with your health care team is vital. To be sure nothing is missed, take the time to collect your medical records from all the doctors you see. This includes notes from your primary care doctor and specialists, tests, and surgery reports. You may want to start with your primary care doctor, the doctor who sees you the most.

To obtain your records, you should submit a medical record release form. This form gives your doctors and other health providers permission to release your records to you. This can be done at the doctor’s office, by mail, or by fax. You can get a record release form at doctors’ offices or at other medical facilities such as hospitals and clinics.

The medical record is your life and health on paper. Once you get your records, it is important to review them for accuracy. If any information is inaccurate or any reports are missing, bring it to your doctor’s attention. You might find some
things your doctor did not tell you about or things you simply do not understand. If your doctor is unable to get the missing information, contact the source directly for copies of your reports.

Gather this information into a folder or notebook. Add a cover sheet with your name, address, phone number, email, and date of birth. On this page make a list of your medical conditions, all the medicines you take, your allergies (and any other reactions to medication), operations you’ve had, and a history of diseases that run in your family. You will be able to make copies to take to any doctor you go to. This also prevents the delay that occurs when records are sent from doctor to doctor, which can take from weeks to months to years.

Best health!

by J.L, Richardson, M.D., family medicine doctor and author of Patient Handbook to Medical Care: Your Personal Health Guide.

Patient Handbook to Medical Care provides 112 pages (large print) of health information that will tell you what your doctor should be asking you, telling you, and doing for you - as taught in medical school and used since Hippocrates.

www.mypatienthandbook.com/

www.twitter.com/MD4U

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Eleven Effective Rules of Communication

1. Listen a lot.
2. Be specific.
3. Ask for a reasonable change that will relieve the gripe.
4. Make sure your partner understands what you want and you understand what she or he wants.
5. Deal with only ONE issue at a time.
6. ALWAYS consider compromise.
7. Never assume you know what the other is thinking. Check it out. Don't assume or predict reactions, rejections, or acceptance.
8. Accept what the other feels. Don't tell your partner what he or she should or should not be feeling.
9. Don't name call or label.
10. Sarcasm is dirty fighting - call each other on it.
11. Stay in the present. Grievances should be dealt with at the earliest possible moment. Don't save them up to use as weapons.

Great health relies on effective communication by everyone - patient, family, and health care team. Best health!

Know Your Medication Names - Brand & Generic

Please welcome, guest blogger, Ellen Richter for this post. Know your medication!

If you take a brand-name drug, you should learn all the other names for the drug. I cared for a patient last month who had been taking Plavix for a mini-stroke since 2001. He knew that he should never stop taking the drug, so when he was hospitalized, he asked his nurse what medications his doctor ordered. She told him baby aspirin and clopidogrel. He never heard of clopidogrel so he called his wife & had her bring in his Plavix. He thought the hospital wasn't giving it to him! Every day, he silently took his own Plavix without telling the staff and then was given the daily dose, in generic form, by the nurses! If only he knew the different names for his drugs! He assumed the generic clopidogrel was a new pill the doctor had started him on!

Ellen Richter, RN, CLNC is a legal nurse consultant and founder of South Florida Legal Nurse Consultant Service, specializing in medical record review.
http://www.findlegalnurse.com/index.html

Tips for Your Doctor Visit

Going to the doctor can be quite a challenge. "Patient Handbook to Medical Care: Your Personal Health Guide" is the perfect tool for patients to make their visits worthwhile.

One of the first things you want to do is make a written or typed medical history to take with you, especially if this is your first visit to a new doctor. Make a copy for you and your doctor. You both will be able to refer to it as needed. This will save valuable time, and give you and your doctor more time to talk instead of flipping through your medical record. It can be difficult trying to "remember" what test or procedure you had 10 years ago.

Start keeping a list of things you want to talk to your doctor about. Update the list before each visit. This way you will be able to keep track of what has been discussed, and what needs to be discussed. Try to talk about the most important things first especially those that need immediate attention. Each time you go for your visit, you can refer to your list and take up where you left off. Be sure to express your immediate concerns first. We all know how short a doctor visit can be.

Request copies of your medical records from all your doctors. "The medical record is the cornerstone of keeping track of everything pertaining to your health." You will be able to check the accuracy of your records, and bring any errors or absent information to your doctor's attention. Let your doctor know about anything you do not understand, or if there is something you are unable to read due to legibility. It is surprising to see how many doctors are often unable to read their own handwriting.

Stay on top of your health care with these tips. After all, great health is true wealth!

P.S. What tips do you have for doctor visits? Share your tips for doctor visits. Click on "comments".

http://www.mypatienthandbook.com/

MEDICAL HISTORY FORM

Your medical history is the cornerstone of your medical record.

Print, fill out, and use it to keep up with your health.

Share it with your healthcare providers, and take a copy with

you when traveling.

MEDICAL HISTORY FORM

NAME__________________________________________

DATE OF BIRTH______________________

SOCIAL SECURITY NUMBER_____________

INSURANCE COMPANY__________________

INSURANCE ID #_______________________

PHONE_____________ FAX___________

ADDRESS__________________________

CITY_________________STATE______

ZIP_______COUNTRY_______________

EMAIL______________________________________________

PAST MEDICAL HISTORY

ALLERGIES______________________________________________________________________________________

_______________________________________________________________________________________________

DRUGREACTIONS________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

DIAGNOSES & MEDICAL CONDITIONS (include year diagnosed)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SURGERY/ OPERATIONS (include year done)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICATIONS (list prescription, over-the-counter, foods, herbs

also write dosage and how often taken)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PAST MEDICATIONS (list anything you have taken and stopped – note why it was stopped)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

FAMILY HISTORY (list medical conditions in family members – list ages, list if deceased and reason)

MOTHER____AGE________

LIVING: YES___NO____

FATHER____AGE_________

LIVING: YES___NO____

______________________________________________________________________________________________

SISTERS_____AGES_________

LIVING: YES___NO____
_______________________________________________________________________________________________

BROTHERS __AGES_________

LIVING: YES___NO___

_______________________________________________________________________________________________

GRANDMOTHER (Mother's mother) AGE__________LIVING: YES___NO___

_______________________________________________________________________________________________

GRANDMOTHER (Father's mother) AGE__________LIVING: YES__ NO___

_______________________________________________________________________________________________

GRANDFATHER (Mother's father) AGE__________LIVING: YES___NO___

GRANDFATHER (Father's father) AGE___________LIVING: YES___NO___
______________________________________________________________________________________________

OTHER RELATIVES (list any more sisters, brothers, great grandparents, etc. especially those with medical conditions)_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OTHER MEDICAL TREATMENTS (list any other treatments like prayer, massage, chiropractor, exercise, physical therapy, etc.)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

SOCIAL HISTORY

Home: lives alone___

lives with family___

lives with friend____

lives in facility_____facility name, address____________________year moved in____________

Marital: Single___Married____Divorced___Widow/Widower_____

Use of cane___ walker___ wheelchair___prosthetic_____

Other___________________________________________

Alcohol consumption:

How many times per day/week/year?________________

How much per drink?____________________________

Cigarette use: Yes___ No___

How many per day?________

At what age did you start?_______

Sexual: Are you active? Yes___No___

Drug use: Yes___ No___

OCCUPATIONS/ JOBS/SCHOOLING

______________________________________________________________________________________________________________

MY MEDICAL NOTES

Use this page to list any other medical history

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Self Check You

We the people of this mighty fine country vow to take the absolute best care of our most important asset - US. A nation is as great as its assets. We have so many. As long as us Americans stay healthy, we will stay wealthy.

True wealth is great health. It is time for you to take responsibility for your health. It is time for you to know what your health numbers are. It is time for you to know your medical conditions, risk factors, and family medical history.

Give yourself a medical checkup. Start by writing or typing or recording your medical history - medical conditions, surgery, treatments, family history. Add your medication. Save it. Update it. Add to it. Correct it. Keep it current. Keep a copy in a secure place.

Examine as much of yourself as you can. Look at your skin, hair, nails, eyes, teeth, and every part of your body that is visible to you. Make note of any abnormalities. Make note of any symptoms you have - new, old and ongoing. Go through each body system. Add this information to your medical history. Add to this your doctors' and health care providers' names, phone number, land address, and email address.

Call your doctor for an appointment for a comprehensive CPE (complete physical exam). Take your information and notes with you on your appointment. Review everything with your doctor. Take notes.

Sign a medical record release to obtain a copy of your medical record from each doctor you see at the time of the visit.

Be sure to schedule a follow-up appointment within a month or less to go over everything with your doctor. Get copies of your information including blood tests, and any other tests as well as medical notes.

Take charge. Be the healthiest you can be - as a person, as a nation.

Great health is true wealth!

J. L. Richardson, M.D., family physician patient advocate, is author of Patient Handbook to Medical Care: Your Personal Health Guide.

Your Medical Record

Recently I reorganized my medical records. I started getting copies of them when I was in college. It was at this time that I was diagnosed with a medical condition that required surgery for a cure. That is pretty shocking. I decided that after several years of doctors’ testing and untimely diagnosis I must see what is being written about me.

By getting a copy my medical record from that doctor, I was more informed. Thereafter I continued to get copies of my medical records including blood tests and all other tests as well as surgery notes. I also started doing it for my parents and my whole family. Your medical record is the cornerstone and foundation of your medical care. It is the most important communication aside from direct patient to doctor conversation.

It sure would be nice to write it all down. The doctor writes, types, or dictates as much as possible. This important conversation including what is found on the physical exam, the diagnosis/ diagnoses, an assessment of tests done, and a plan for treatment is documented by writing, typing, or dictating. That is a lot of information to document. Accuracy is of utmost importance. The medical record is the communication tool used by all your health care providers.

It is only right that you should be able to see your medical record about you. Checking for accuracy and information in your records is important. It is empowering. It makes you want to take the best care of yourself, and be able to talk more openly to your doctor about it. I have found this to be true amongst patients that keep their medical records. I have seen medical errors avoided. I have learned more from patients about their own medical conditions because they read about them.

The best way to obtain your medical record is to obtain a record release form. Your doctors’ office should have this document. Ask for it. After completion return it to the person in charge of medical records at the office, hospital, or other medical care facility via mail, fax, or in person. A copy of the medical record is sent directly from the office, or it may be sent from a company that sends out medical records. How this is done is beyond me especially when the company is in another state. Getting the record directly from the health care provider seems easiest for the patient.

Sadly, you may have to pay for your records. It is best to get copies from your doctor at the time of your visit. Most doctors have it finished by the time you leave. When tests are ordered, the results can be faxed or mailed after your doctor talks to you about the results. This may avoid costs, and help ensure timely follow-up. I have found some doctors’ offices automatically give you this information. How nice!

Medical record retrieval can be challenging, but rewarding. Keeping current with your health is your job. You are your most important asset.

Information on obtaining a medical record release at http://www.mypatienthandbook.com/ under "Patient Tools”.

--by J.L. Richardson, MD, family medicine, is author of the award winning Patient Handbook to Medical Care: Your Personal Health Guide".

http://mypatienthandbook.com