Make sure your health care team has all the information it needs to diagnose your problem and provide treatment.
By Mary Jane Meadows
March 2003
Whether you are a weekend traveler or a full-timer, your health “” and the possibility that you may need health care “” follows you wherever you go. No matter whether you’re in your hometown or on the road, it’s your responsibility to provide accurate information about your medical history when you need urgent health care.
While traveling through Colorado in our motorhome during the summer of 2001, I became acutely ill. My husband drove me from our campground to the nearest small-town emergency room at 1:00 a.m. From there I was transferred by ambulance 175 miles to a major hospital in Denver where I was admitted for tests and treatment. Upon leaving Denver, we traveled to Kentucky, where we have family, and I received more tests and treatment. We finally arrived at our new home in West Virginia, where I found a local physician to become my primary caregiver. With each new medical contact along the way, we were questioned about my medical history as well as current problems and treatment. As a health care professional, I thought I was prepared for such a situation. I was not.
I am a registered nurse and health information management (medical records) professional, so I am familiar with the information that medical personnel require to enable them to make accurate diagnoses and treatment recommendations. What I had not taken into account was the impact stress would play in my ability to think clearly. While I was ill, I could not recall some of the pertinent information about my health history, and when seeing each new physician, I could not remember all of the details of what the last doctor had said. This experience has taught me to take a personal medical record with me when I see a physician.
For anyone who is treated as an inpatient or who undergoes a major outpatient procedure, a physician must dictate or legibly write a history and physical examination, which includes the patient’s current health problem; a social history (alcohol use, tobacco use, recreational drug use, etc.); a medical history; a surgical history; known allergies to medication and food; and a list of current medications (prescription and over-the-counter drugs, as well as herbal supplements taken on a regular basis) with the dosage and schedule. This is information a patient or family member must accurately provide the attending physician, even under extreme duress, as in an emergency situation.
To help you or your family member remember all of that information, you should consider creating a brief typewritten or handwritten summary of your medical history. This history may take some time to prepare, but it could save your life. Carry your health summary in a wallet or purse at all times, and update it as necessary. If the piece of paper is too large or bulky to fit in your wallet, use a photocopy machine to reduce the size so the print is small but legible.
The physician is required to dictate a report for each procedure or surgery performed in a hospital — from X-rays to open heart surgery “” which is then typed by a medical transcriptionist. For inpatient admissions, a discharge summary is prepared in a similar manner. As a patient, you have a right and responsibility to obtain a copy of this document. If you are treated while traveling, you should ask the doctor to provide you with a copy before you’re discharged. These reports can be transcribed on an urgent basis if necessary. Whether you visit a new health care center or doctor, or return to your primary physician, medical personnel will have a better understanding of your condition if they can read and retain a copy of the information for your office or hospital medical records. But do not give away your personal copies of the reports. Ask the office personnel at the medical center or doctor’s office to make photocopies.
Carrying along your personal medical records and obtaining copies of doctors’ reports are essential. You also may wish to keep documents such as a living will, a health care advance directive, or a durable power of attorney for health care with you as you travel.
Anyone traveling with you, such as friends or grandchildren, also can become ill. Therefore, you’ll want to have information about their immunizations or major illnesses, in case you need to supply it. Accurate information is a key component of quality care.
It is important for people to be knowledgeable about their own health and medical conditions in order to monitor their care and be active participants in treatment decisions. Physicians see many patients and cannot remember precise details about every one of them. As patients become more involved in tracking their own health care, they experience improved outcomes, and the patient-provider relationship evolves into more of a partnership. You are probably the only person who is present at every visit you make to a health care provider. And you are the one person ultimately responsible for making your medical history known to your physician or medical team.