What information should my personal health record contain?

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Dr. Kathleen Handal, MD
Emergency Medicine Specialist

Here’s a sample health history sheet (medical history/medication list):

Name: Mary D. Smith (Include middle initial)
Date: June 1, 2010 (last updated)
Date of birth: 1/1/1955
Physician’s name(s)/phone numbers: Dr. Barry Jones, General Practitioner, 401-332-3333; Dr. Lee Stark, cardiologist, 401-523-3343
Insurance company/phone number: ACE Insurance, 444-444-1111
In case of emergency (ICE) contact person/phone numbers: Don D. Smith, son, 443-323-2333 (home), 443-230-4655 (cell)
Clergy: Rev. Brian Clifford, 401-232-1131
Allergies: penicillin (rash), latex (rash), shellfish/iodine (anaphylaxis)
(List all medicine, food and environmental allergens. If you’re allergic to penicillin, describe the type of reaction you had when you took it. Allergies to shellfish are important to mention because some contrast dyes used in medical testing contain iodine. Latex allergies are important to note because latex is used in medical equipment and gloves.)
Medical history: hypertension (diagnosed 1999), insulin-dependent diabetes (diagnosed 1999), heart attack (2000), diverticulitis, cancer left breast (2002), hypothyroidism (diagnosed 1999)
Surgeries: left mastectomy (2003), appendectomy (1993)
Implanted devices: pacemaker left chest wall
(Remember, if you are being treated for a condition, even if it is well controlled, you still have that condition, so list it. Note if you have any metal in your body, including implants, shrapnel or implanted medical devices.)
Family history: lung cancer (mother, deceased 1999), diabetes (father), hypertension (brother)
Current prescribed medications:
Two Lasix 20 mg (total 40 mg), twice a day for high blood pressure
Aspirin 81 mg, daily
Simvastatin, 40 mg, daily for high cholesterol
(Be sure to note the dose along with how many of each pill you take and how often. Double-check your spelling, pronunciation and the dosing information against the bottle.)
Over-the-counter (OTC)/herbal preparations:
Co-Q, red yeast rice, vitamin C, calcium, gingko
(Your health care team needs to know if you’re taking any OTC medications because they, too, have side effects and interact with other medications.)
Vaccinations:
Flu vaccine: (date) 11/1/09
Pneumonia vaccine: 10/20/07
Tetanus: 2/3/99
The medical professionals who treat you will appreciate the time and effort you have spent maintaining your health history information. Believe me, you’ve gained their respect by helping them do their jobs.

Your ER Survival Guide: What You Need To Know Before You Go (DocHandal's Guides Book 4)

More About this Book

Your ER Survival Guide: What You Need To Know Before You Go (DocHandal's Guides Book 4)

Few people get through life without at least one trip to the emergency room (ER), either as a patient or support person for a family member or friend.  "Your ER Survival Guide" is the new title for "Doc's ER Survival Guide" it is for non medical persons! It is designed to help calm readers' fears by giving them the lowdown on how an ER operates. The book is written by Kathleen Handal, MD, an emergency physician with over 20 years experience. Handal is a nationally and internationally known emergency medicine physician who authored "The American Red Cross First Aid & Safety Handbook" and co-authored a series of medical textbooks. Included are ten simple steps to follow to get ready for an ER visit, as well as valuable insight into how an ER operates so readers can advocate for the best care possible. Complicated tests and terminology are explained in easy-to-understand terms.Doctors and nurses are making decisions in a fast-paced, stressful environment. Mistakes can and do happen. So the more people know about what to expect the less likely one of those mistakes will happen to them. Reading the book is like having Doc Handal at your side when you need her the most.
Betty Long, RN, MHA
Nursing Specialist

At the very least, we suggest you start with these basic components:

  • Personal identification
  • Emergency contacts, including phone numbers
  • Healthcare provider contacts, including specialists and dentists
  • Health insurance information
  • Living will, advance directive, or power of attorney
  • Organ donor authorization, if any
  • Current medications and dosages
  • Significant illnesses and surgeries, with dates
  • Immunizations and their dates
  • Allergies or other sensitivities
  • Results from most recent physical exam
  • Test results and eye and dental records
  • Family health history
  • Opinions/consultations from specialists
  • Correspondence/letters/phone calls with physicians

It should include information from your medical records, but it can also include your own notes, contact numbers and other information. Here's a good list to start with:

  • Name and birth date
  • Blood type (A, B, AB, O)
  • Emergency contact. This should be your spouse, parent, adult child or other person you want to be contacted in an emergency.
  • Prescription information, including dosage. If you need medication or some other form of treatment, the medical professionals treating you need to know what you’re already taking.
  • Allergies. This information helps professionals determine if you're having an allergic reaction and it prevents you from being treated with drugs to which you react badly.
  • Date of last physical, lab work, screenings and results. Knowing when you had tests and checkups can help you avoid unnecessary repeat tests. In addition, in times of stress you don't want to rely on memory for medical details.
  • Dates of major illnesses and surgeries.
  • Any chronic diseases from which you suffer.
  • Living will and advance directives.
  • Family medical history. You may need to ask other family members for help with this information.

The specific content of your health record depends on the type of healthcare you have received. Listed below are documents common to most medical and health records, as well as additional documents accompanying hospital stays or surgery. Consider including the following items in your personal health record (PHR):

  • Personal identification, including name and birth date
  • People to contact in case of emergency
  • Names, addresses and phone numbers of your doctor, dentist and specialists
  • Health insurance information
  • Living wills, advance directives or medical power of attorney
  • Organ donor authorization
  • A list and dates of significant illnesses and surgical procedures
  • Current medications and dosages
  • Immunizations and their dates
  • Allergies or sensitivities to drugs or materials, such as latex
  • Important events, dates and hereditary conditions in your family history
  • Results from a recent physical examination
  • Opinions of specialists
  • Important tests results; eye and dental records
  • Correspondence between you and your provider(s)
  • Current educational materials (or appropriate web links) relating to your health
  • Any information you want to include about your health, such as your exercise regimen, any herbal medications you take and any counseling you may receive
  • Dietary practices, such as whether you are vegetarian or on a temporary diet, especially if changes in your diet have produced changes in your health in the past

Continue Learning about Managing Your Medical Records

Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.