Your own Medical Record

We strongly advise all my patients with more than one medical problem or who use multiple medications to keep an ongoing written medical record.  This should be kept with you and brought to all appointments.  This includes specialists, emergency visits, and testing.  The result will be a smooth and much more efficient visit or hospitalization. We recommend that you divide the book into the following sections:

 

Section 1. A section with your name, phone number, address, health card number, date of birth, and emergency contact numbers.  This section would be accessed should you be unconscious or unable to give the information.

Section 2.  Would be a list of your health problems.  This can be one worded.  Example diabetes, hypertension, stroke, etc.  This section requires no more than 2-3 pages.

Section 3.  Would be past medical health.  In this section you would include, allergies, operations that you may have had (the place and the year), any major accidents, things such as this.

Section 4.  Medications.  You should devote about 10-15 pages to this.  It is termed medications.  List each medication, including the full generic name and which company produces it, the dosage and when you take them.  You should include vitamins, and over the counter Aspirins, as well as, any drops, and herbals that you may be using.  This section would be updated by your doctor or anyone who should decide to start you on a new medication.

Section 5. Tests and visits should also be about 10 pages of length.  In this section you would keep a chronological date in order of visits to your various specialists and testing which is being performed.  For example you would list when you had your mammogram or chest x-ray.  This section is also vital because it allows specialists and your family doctor to communicate.  For example, I would list your blood pressure and perhaps a note to your cardiologist which you could than show your cardiologist at that visit.

Section 6.  In this section, list your immunizations such as flu shots, pneumonia shots, or your last tetanus shot.  It is also useful to list any travel shots which you have received here.

Section 7.  Would be a special section of your own choice.  In this section you could track your own blood pressure, weight, and blood sugar for example. 

 

It is most important that you keep this record with you.  Consider it confidential and mark it so.  The only risk you take is that someone else may glimpse at your medical history.  Some of our patients actually keep their record in an electric form using a small smart token, or print, or burn an updated CD with their information which they keep with them at all times.  Either of these methods is acceptable.  This record may end up saving your life one day.  It will certainly allow any emergency physician or specialist who does not know you to become acquainted with your history quickly and in this will provide you with a much more appropriate medical opinion.  We look forward to seeing your new medical record at your next visit. It also provides a method to communicate between all doctors who are treating you.