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Creating a Personal Medical History

caregiving
Personal Medical History

Imagine this. You are at the doctor's office. You are filling out those never-ending medical history forms. You speed through them with handwriting that would make your first-grade teacher gasp in horror. You go in and see the doctor, which lasts all of five minutes. You leave and go about your day tackling all your to-dos. Until out of nowhere, you remember. You forgot to add a few details on your personal health history. Maybe it was a minor procedure, a few symptoms, or you forgot to list a medication. 

This scenario is probably not that hard to imagine because many of us have been there and done that. After all, it's hard to remember our medical stuff, let alone someone else's medical history. Knowing a person's medical history is a timesaver and may even be a lifesaver. The best thing you can ever do for yourself and your loved ones (especially elderly parents) is to keep an up-to-date medical history that's easily accessible. 

 

The key phrase here is easily accessible. If you are taking your parents (or, in my case, my grandparents) to their doctor's appointments, you need to reference information that's easily forgotten. For example, when the doctor asks what's the dosage for a particular medication. You can look it up. You have a lot on your plate these days, so it's easy for things to slip our minds. A grab-n-go personal medical history binder is one way to solve this issue.

 

My mom came up with the idea to do a 3-ring binder because my grandparents were going to their doctor's appointments, and they would forget things. We created this binder well before they needed full-time care. My grandparents didn't have computers, WiFi, or smartphones, so it had to be low or no technology. We put it together for them and reviewed or updated it when we visited. They would take it with them to each doctor's appointment. Most of the nurses and even some of the doctors would comment on it. They loved seeing the information all in one place. 

 

Why Do you Need to Have Personal Medical History?

 

Having a personal medical history is essential no matter what stage of life. If you are caring for an aging parent, this will help you keep everything organized. If your parents are still actively taking care of their health and going to doctor's appointments, this is still a valuable tool because as we get older, we forget things. Overall, this can make them feel more confident and give you more peace of mind if you cannot go with them. Let's look at why you may want to have a personal medical history readily accessible. 

 

#1 You never know when you will need it. 

 

When it comes to caregiving, you never know what will happen or when. One day your loved one might be fine, and the next, you are calling 911. You don't want to be running around trying to find all the information or freaking out in these moments because you can't remember every little detail. It would help if you had something that is organized and ready to go. 

 

Another scenario is when you are changing to different levels of care. For instance, maybe the person you are caring for is entirely self-sufficient, but recently they had an accident or setback. Now they need palliative care or home health hospice. If that's the case, healthcare professionals will be coming into your home asking you the same questions over and over again. Having these medical records will help you answer their questions thoroughly and with confidence. Trust me, it helps! 

 

#2 It serves as a system of checks and balances. 

 

Have you ever had to go to multiple doctors and specialists? Have you ever had to get a referral or dealt with insurance companies so that you see a specific doctor? It can take weeks and many phone calls between the primary care physician, insurance company, and the specialty doctor's office. This process can make you feel overwhelmed, frustrated, and exhausted. Sometimes things slip through the cracks, or there will be incorrect information on the referral document, which only causes further delays. But if you have all your records together, you can potentially catch any mistakes before they happen. 

 

#3 It's a timesaver. 

 

Saying life is busy these days seems like an understatement. We need all the help we can get, so being proactive now can save frustration later. Here's an example. If you keep copies of all the current medications and supplements, instead of filling that section out on the forms, give them the copy. Otherwise, you spend all that time filling out those forms only for the doctors to ask you about the medications and supplements you are taking that should be in your chart. Instead of fumbling your way through and trying to remember all the details, you can give the doctor a copy to review. 

 

What's the best format for your patient history record (PHR)?

 

My grandparents were part of the "Silent" Generation, those born between 1927 and 1946. This generation precedes the Baby Boomers. These individuals may not be tech-savvy, so do what's best and easiest for all parties. What option you choose depends on your situation. Here are a couple of questions to think through: 

 

Who is going to use it? 

What's the easiest method for that person? (Ask them)

Who is going to keep it up to date? 

Can it be taken with you?

 

It's essential to think through these questions with your loved one. If they don't like technology, then make sure they have something that they can physically take with them to doctor's appointments. You don't want to force them to use an app when they can barely use a flip phone. 

 

Also, think about where you are in the stage of your caregiving journey. My grandparents used the binder method for keeping all of their information in one place because they were still going to their doctor's appointments alone. When they needed someone to go with them, we could have switched to an app at that point to make it more convenient for us. But we didn't do that because it was easier to stick with the binder as we didn't need one more thing to think about during that time.  

 

Here are the main two methods to keep medical records organized:

 

  1. Three-Ring Binder

 

This method is pretty self-explanatory. We had a three-ring binder with tabs. If you take care of more than one person, you can either choose to have a separate binder for each person or combine them into one. Scroll down for the details on what information to include. 

 

  1. eHealth Apps, Tools, and Software

 

Another option for those more technical is eHealth tools, which are all about accessing your records electronically. This category includes apps, internet-based programs, or software that allows you to manage one's health and keep all information together.  

 

I have not personally used any of these; however, here are a few of the names that came up in my search to get you started.

 

Examples include Apple Health, CareZone, GenieMD, Healthspek, HealthVault, Medical Records, My Medical, MTBC PHR, myPHR, and many more. 

 

If this is the method you choose to take, do your research and make sure your information is safe, secure, and HIPAA-compliant. Should you want to do additional Google searches, try using the keywords: eHealth Tools, Electronic Medical Record Apps, Patient History Record Apps, EMR Apps, PHR Apps. Add the current year to your Google keyword search if you want the most up-to-date. Example: eHealth Tools 2021.

 

Alternative Options:

 

Additionally, you can track and store your medical information by scanning documents and lab results you receive from the doctor and typing up any additional notes on your computer. You can password-protect them or upload them to an external hard drive used only for your health records. Another route is to get a filing cabinet or accordion folder or even a personal safe or lockbox to store the information, so any sensitive data is protected. 

 

Choose the method that is best for you and your loved ones. Remember, apps come and go. Sometimes technology goes crazy, and you can't access it, or your phone runs out of juice or dies completely. What will you do then? If you want to do an electronic version, I would recommend that you keep some physical copies of your medication list and legal documents on hand just in case. 

 

 

Do you still need to organize your PMR if you have access to patient portals?

 

Short answer: Yes

 

Longer answer: Patient portals are great, and most doctor's offices have one. When you are caregiving (especially remotely), you want to have permission to call the doctor's office on behalf of your loved one and have access to their patient portal. Of course, you need your loved one to fill out the necessary forms to give that doctor's office permission to talk with you. If there are multiple caregivers, then add them if necessary. 

 

For instance, when we were taking care of my grandfather, my mom and uncle were the only ones on the list. But I needed to be added because there were times when I was taking care of him by myself, so I needed to call and ask questions as needed. Depending on your situation, you may need to update this as you go along. 

 

A note on privacy: 

 

Your medical records are personal. You need to have access to a patient's date of birth and a lot of other information that needs to be kept secure and private. I would not add strangers or care-for-hire on any personal forms. If they are a healthcare professional, then they will have their access. You may only want to permit family members to talk with doctors or access patient portals for privacy and security reasons. 

 

Ultimately, use discretion. If you are not sure or have any disagreements within your family, seek professional advice from a legal expert or talk to the doctor's office about it. 

 

 

HOW TO CREATE A PERSONAL MEDICAL HISTORY

 

First, you want to choose your preferred method, as mentioned above. If you use eHealth tools or apps, then they will dictate the information included. If you decide to kick it old school (like me) and use a 3-ring binder, here are the things we added. 

 

Patient Details

Some people include patient details like their name, date of birth, blood type, insurance information, etc., which comes down to personal preference. You may want to be cautious about what personal information you put in this binder for privacy and security reasons. 

 

Medications Vitamins and Herbs

Type up a list of your medications, vitamins, and herbs. You want to include the name of the drug, dosage, when you take them, why you are taking them, and who prescribed them. You can also list the medications that one's doctor has discontinued. Many doctors will give you a summary of their visit; however, it's a huge time saver to have this typed up and have multiple copies on hand should anyone ask or you have to fill out any forms.  

 

Allergies

Include a list of all allergies such as drug, food, insect, latex, mold, pollen, and pet. 

 

Medical History - 

Include a list of procedures, surgeries, chronic conditions of any diagnosis that has been made by a health care professional. Include the date or at least the year that these occurred and list these in chronological order. 

 

Doctor Summaries 

Many doctor's offices include a summary of each visit. They will either give you a physical copy to take home with you or send one electronically via the patient portal. You can add any physical documents to the binder and print out anything online that's important. 

 

Test Results/Labwork/Pathology

Include hardcopies of results from any annual checkups (such as bloodwork) and any testing such as an X-ray, CT scan, MRI, etc. You can include a printed copy of the results for quick reference.

 

 

Doctor's Contact information 

Include contact information for all doctors and specialists. You can either handwrite or type this information out. Or grab a business card from each office and put them in clear plastic business card pages for 3-ring binders. You can find these on Amazon or at any office supply store. This way, you will always have access to their name, specialty, and phone number. 

 

Legal documents. 

If there are any legal documents, include them in the binder so they are all together. Examples of documents include: Do Not Resuscitate (DNR), Living Will, Power of Attorney (Healthcare or Financial), Designation of Healthcare Surrogate, etc. Put each document in a sheet protector to keep them from being damaged or torn. Keep originals and only give copies on an as-needed basis. Consult legal professionals or your primary doctor's office for any questions. 

 

*NOTE: This is not an exhaustive list of legal documents. Some forms will be different depending on your location. 

 

Miscellaneous 

You can add any additional tabs you think might be relevant to your situation. If you have any articles or research you want to discuss with your doctor; you can file those in your binder as well. You can include loose-leaf paper to write any notes or questions from each doctor's visit. 

 

 

I don't recommend making a cover for any medical records binder. You don't want to shout to the world that this binder includes all of your medical information. But have this someplace where you can remember to take it to each doctor's appointment. 

 

When you care for a loved one, you never know what you will need or when an emergency will occur. So no matter what method you choose, preparation is critical. 

 

This article serves as a guide that will get the ideas flowing. Feel free to add or take away things based on your situation. Ultimately, having quick access to one's personal medical history, whether for you or a loved one, will save you time, frustration and could make a massive difference in your caregiving journey. 

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