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Family Medical Records (cont.)

Important Information to Have in Your Personal File

Essential medical information will be different for each person. Although it may not seem relevant, knowledge of even the smallest medical detail could potentially provide critically helpful information. Keeping an up-to-date and concise health record for oneself and family members is strongly recommended for everyone.

It is a good idea to have a more complete list at home and more brief copy, ideally on one page, with you at all times. Nowadays, many people have a document for their personal health history on a home computer and they can easily update it after each doctor or hospital visit. They can then print this document and have it handy and available for unexpected medical situations. There is also computer software available that can keep and organize family medical records.

Some of the essential personal health records that should be kept in one's permanent file at home may include the following:

  • Major medical problems: a complete list of all current and past medical problems. This should include chronic diseases such as diabetes, asthma, emphysema, high blood pressure, high cholesterol, HIV/AIDS, cancers, strokes, heart attacks, ulcers, etc.
  • Other medical and surgical history: list of any illnesses, hospitalizations, or operations you have had. This list should be comprehensive and should include a history of cigarette smoking history, alcohol consumption history, sexually transmitted diseases, serious infections, and major or minor operations, and mental-health disorders.
  • Childbirth: Women should add a history of childbirth, including miscarriages, abortions, and cesarean sections as well as natural births and even adoption history.
  • Current medications: a comprehensive list of any current medications with dosages and frequencies (how often taken). Medicines such as blood thinners, water pills, blood pressure pills, antibiotics, and antiseizure treatments have important interactions with one another and other drugs. Doctors need this information to avoid potentially dangerous reactions. Included with this medication list should be any herbal, alternative, or over-the-counter medications you take because all of these can have potentially important effects on your treatment. Finally, keep a log on the type and dates you were immunized including the date of your last tetanus booster.
  • Allergies to medicines: Equally important is a list of all medical allergies and significant food allergies (peanuts, shellfish, etc.). Some people have very serious allergies to common medications. It is essential for doctors to know this information when treating people. When known, the precise type of allergic reaction should be listed (itch, rash, hives, difficulty breathing, swelling, anaphylactic, or near fatal experience, etc.). Intolerances to medications are also important to note (such as nausea, vomiting, abdominal pain, headache, confusion, etc.).
  • Family medical history: history of high blood pressure, heart disease, diabetes, blood clots, cancer, and other conditions in blood relatives. This history can affect how you are diagnosed and treated. Most important are the histories of parents, siblings, and children, but medical information about other family members may be pertinent as well.
  • Phone numbers: phone numbers of family members, treating doctors, therapists, pharmacist, or other health-care professionals. Each of these professionals can provide valuable information and can be very helpful during emergencies.
  • Medical data: Some medical data are also important to have in personal medical records. Some examples include any abnormal laboratory tests or examinations (blood counts, kidney and liver functions), heart catheterization and stents, pacemaker, chest X-ray, etc.
  • Children's information: You need to keep copies of your children's medical history as well. This should include not only all of the information above but also a record of their childhood immunizations. If the child is old enough, he or she should be encouraged to carry their own medical records and contact phone numbers.
  • Advance directive, power of attorney for health care: It is very important to have legal documents in place stating whom they designate to make decisions for them when they are unable to do so themselves and what their wishes may be. Frequently, family members and doctors are left with very difficult life-and-death decisions to make about patients who are in a condition where they are incapable of making decisions about their own care (confused, unconscious, on artificial breathing machine, etc.). By having prepared these documents ahead of time, the burden of decision-making is lifted from family members in these tough situations and, more importantly, the patient's wishes are respected. The power of attorney for health care can make decisions based on what they know the patient would want in a particular situation. Typically, your primary doctor can guide you in this process. These are legal documents and are generally filled out with the help of an attorney.
  • Individual's decisions about end-of-life decisions and physician orders for life-sustaining treatment (POLST): Each individual may have a different view as to how they would want to be treated in critical medical situations in terms of heroic measures and artificial means to sustain life (placement on a breathing machine, performing CPR, artificial feeding, etc.). POLST is a new form which first became available in Oregon in the 1990s, and now it is available in many other states. This is a single page in a bright color that is filled out by the patient and signed by their doctor. It addresses the patient's specific wishes for particular clinical situations where life-and-death or life-sustaining decisions may be necessary. This form, or a copy of it, should be carried with the patient at all times.
Medically Reviewed by a Doctor on 12/5/2014

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