Summarize Your Own Medical History

Medical schools teach that the most important step of making an accurate medical diagnosis is not the physical examination or expensive medical tests and equipment. The doctor is best served by taking a complete patient history. Surprisingly, most people do not know or remember many of the details of their own health. This is a frustration to all health professionals, and can contribute to a misdiagnosis and medical errors. Technology will eventually catch up with our need to have timely access to medical information. In the meantime, follow these steps to create a quick record of your past medical history.

Steps

  1. Request records from your primary care doctor. Explain that you are trying to maintain a personal health record, that they have your records and that you need and have every right to access them. If the office is using a modern computerized charting system, or if the doctor has been particularly diligent with the paper charts, a "Front Sheet" or "Cumulative Patient Profile" (CCP) may already be available to print or photocopy. If available, use the CCP to assist with the following steps.
  2. Write down your demographics. Include the following:
    • Full name
    • Date of birth
    • Sex
    • Health insurance information (provider, policy number)
    • Next of kin and/or Power of Attorney for Care
    • Addresses and phone numbers
    • Name and phone number of primary care provider
    • Name and phone number of pharmacy
  3. List your medical, surgical and family histories:
    • All known medical diagnoses, past and present
    • All surgeries, with name of surgery, date, and outcome
    • Allergies, especially to medications, and what reaction you had
    • Names, specialties, and phone numbers of any physicians who are still following you
    • List significant diagnoses or severe illnesses of close family members, such as parents and siblings.
  4. Include a complete list of the medications you are taking:
    • Prescription medications including dose and number of times per day taken.
    • Specialized treatments such as chemotherapy, drug trials, medication injections
    • Over-the-counter medications, i.e., Tylenol, Gravol
    • Herbal remedies, vitamins and supplements
    • Cigarettes per day
    • Alcohol consumption per day (average), week, or month
    • Recreational drugs, if any (marijuana, cocaine, etc.)
  5. Summarize the results of any medical tests you have access to.
    • Most recent sets of blood work (if there has been a significant change, include the older set too)
    • Written report of x-rays and scans (there is no need to bring the actual films or CD unless seeing a specialist in that field)
    • If you have ever had any cardiac issues, a photocopy of your most recent electrocardiogram (ECG). This is very important, as most cardiac care is time-dependent.
  6. Consider writing advanced care directives if you consider yourself elderly, have ever had any life-threatening conditions or have specific care requests. For instance:
    • Full Code - If you are unable to say otherwise, all medical measures will be taken, including life support.
    • DNR - "Do Not Resuscitate"
    • No CPR, no ventilation, no life support
    • No blood transfusions
    • Organ donation authorized
  7. Type out all the info on one side of a single sheet of paper. Sign and date the sheet. Keep this emergency information with you at all times.

Tips

  • Carry a copy of it with you everywhere, in the same place you keep your health card.
  • Update it whenever changes occur (or, if you've used a printout of your medical summary from your primary care doctor's office, just get your doctor to print out a new one). When seeing a new doctor or specialist, ask them to edit the sheet to reflect the changes they want. If you can type an electronic copy of your summary, it will be very simple for you to update it.
  • If you are on many prescription medications, your pharmacy may be able to print out a summary.
  • Whenever registering for an appointment or visiting the emergency room, show the sheet to the first nurse who assesses you and ask that it be shown to the doctor. Also, be sure to show the sheet to an emergency medical technician (EMT) or paramedic should an ambulance be called for you.
  • If you are elderly, infirm or have medical conditions that may prevent you from speaking for yourself, tape a sealed copy of the document to your fridge or medicine cabinet with a bold label on it. Many EMTs are trained to look there for extra info.
  • Consider e-mailing a copy of the Cumulative Patient Profile (CPP) to yourself and to anyone who plays a role in your care (family or a Power of Attorney). That way, it is always available online even if it gets forgotten at home.
  • Being organized helps to keep your records updated all the time.

Warnings

  • Do not omit or falsify any information. Your life may depend on the accuracy of your summary, particularly if you come to the hospital in a critical state and cannot speak for yourself.
  • Don't assume that technology will make your job as a patient easier. People are on a larger variety of more complicated treatments. They are living longer with diseases that used to be fatal. There is a greater (and unmet) expectation on the part of the public that, somehow, all their medical information is available by computer and shared between all relevant parties. Up to now, this is NOT the case. Even in a modern hospital emergency department, where the most acute care is provided, many patients are treated even when there is no access to any previous health records.
  • This CPP serves the same purpose as a cover letter in a job interview. It's best kept to a single page; if it takes longer to read than it does to hunt for the information in other ways, the doctor may not be able to give it the time it deserves.

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Sources and Citations

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