Handling family medical records at home and in case of emergency.
Here's the scenario: In a busy emergency department, an unconscious man is brought in by ambulance. The paramedics found him on the street, unresponsive but alive, with no obvious signs of what might be wrong. And no one in the hospital knows anything about him.
This scene is all too common in today’s hospitals, where patients often arrive with no family medical records.
The doctor’s job in these cases is very difficult. The doctor must try to treat someone for an unknown medical problem with no knowledge of that person’s medical history.
Has he had a heart attack in the past? And is he having another? Has he accidentally overdosed on one of his medications?
Make sure that you provide all relevant medical records of your addicted loved one when you check him or her into a teen drug abuse treatment facility.
Furthermore, once his problem is diagnosed, the doctors are faced with not knowing the safest way to treat him. Is he allergic to medicines that, if given, could make him worse instead of better?
Does he have medical problems that would make certain treatments dangerous?
With no family in the emergency department, how do the doctors contact the patient’s family and friends to tell them he is there?
Handling Family Medical Records
Important Family Medical Records to Carry
It is because of questions like these that it is so important for people to carry their own medical information. Doctors can most safely and effectively treat you when your medical history is known, rather than a mystery.
What information do I need to keep with me?
Everyone should carry a few basic items of information. But essential medical information will be different for each person. Although it may not seem relevant, knowledge of even the smallest medical detail could potentially be life saving.
Medical problems: First, everyone should carry 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, and cancers.
Medical and surgical history: Also, list any illnesses, hospitalizations, or surgeries you have had in the past. This list should be comprehensive and should include a history of strokes, ulcers, sexually transmitted diseases, serious infections, and major or minor operations.
Childbirth: Women should add a history of childbirth, including miscarriages, abortions, and cesarean sections as well as natural births.
Current medications: You also need to carry a comprehensive list of any medication you are currently taking, how much you take (dosage), and how often you take it. Medicines such as blood thinners, water pills, blood pressure pills, and antiseizure treatments can all influence how you are treated during emergencies. Many medications have important interactions with one another. 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. Also, list any tobacco or recreational drug use, including alcohol, cocaine, and heroin. 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. Some people have very serious allergies to common medications. It is crucial for doctors to know this information when treating people. Essential allergies to list include aspirin, heparin, penicillin, sulfa-based drugs, and contrast dyes, but any other medical allergy should be listed. Additionally, try to describe the allergic reaction. Did you start itching after taking the medication? Did you develop a rash? Or did you have trouble breathing?
Family medical history
Include a listing of family medical problems. A history of high blood pressure, diabetes, blood clots, cancer, and many other conditions can affect how you are treated in the hospital. Most important are the histories of parents, siblings, and children, but medical information about other family members may be pertinent as well.
Phone numbers: Everyone should also carry a list of important phone numbers. It is important to list not only family members to contact in case of emergencies, but also any doctors, therapists, or other health care providers you see. All of these people can provide valuable information and can be very helpful during emergencies.
Medical data: In addition to this basic information, you should carry individually important medical data. Some people may need to have copies of any abnormal laboratory tests or examinations the medical billing staff would have worked over. Others with heart disease should try to have a copy of their most recent ECG and results of heart catheterization (if they have had one), echocardiogram, or stress tests. Someone with anemia or HIV should try to list their most recent blood counts. Similarly people with liver or kidney disease need their most recent liver or kidney test results. Very often your primary care doctor can help you decide what information to carry.
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 just listed, 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.
How to Access Medical Information
How should I carry all of this information?
It would seem impossible to carry all of this information with you at all times — even impractical. Fortunately, there are a number of reasonable alternatives to carrying a photocopied medical chart.
Summary: The simplest solution is a 1-page summary of your medical history. This single piece of paper could be carried in a purse or wallet and should be kept with you at all times. The information should be complete but should be written as brief lists rather than as sentences or paragraphs. Attached to this list should be photocopies of an ECG or other special tests, if applicable. Again, your family doctor may be able to help you determine what is important for you.
Electronic records: The Internet provides another option for people to keep their family medical records. Many companies have developed websites designed for recording medical information that can be reached from any computer with Internet access. Some of these companies even have options for printing a summary of the information that you can carry with you. Also, some of the sites are designed to allow doctors access to the information in emergencies. See the websites at the end of this page.
Wireless access: The increasing popularity of handheld personal digital devices and other handheld computers allows you the option of electronically maintaining your medical records. A number of companies and individuals have developed software for these personal data assistants that is specifically designed to hold medical information. These programs can be obtained from the Internet. Although some are free, many require a registration fee to obtain the complete program. Software titles include Medical Records v10.2, Medical Records v2.0, Personal Medical Records v2.14, Family Medical Records v3.0, and 4T Medical v1.3. (Please note: This list is for reference purposes only. The authors have not evaluated or endorsed any of these products and have no financial relationship to any of them.)
Why Carry Records
Why should I have to keep this information? Isn’t that the doctors’ job?
Similar to the example in this discussion, patients often arrive at hospitals without any information about their medical problems. This presents a difficult and potentially dangerous situation. Although the tests and medicines doctors have are very powerful, they can also be unsafe if used on the wrong person. Knowledge of your medical problems can effectively prevent giving you the wrong medication or performing a risky test.
Additionally, many of these tests are time consuming and can delay important treatments. If you carry their own medical information, it can allow doctors to save time and provide care more efficiently. In an emergency, this can sometimes mean the difference between life and death.
These tests can also be very expensive and might not be necessary. However, when doctors have no knowledge of a patient’s medical history, they are forced to perform these tests at great cost. When patients carry their medical information, this has the added advantage of being less expensive while actually allowing a higher level of care.
Finally, beyond the need to provide immediate care is the importance of contacting family, friends, and physicians. Not only can these people provide important information, but they also can offer much-needed support for you. Having the ability to contact families early in your care can help simplify very complicated situations.
Emergency medical care can be life-saving but is often filled with difficult and expensive decisions that must be made as rapidly as possible. Maintaining your own records is one of the best ways for you to take an active role in your own health care and ensure that you receive rapid, effective, and safe treatment in both emergency and routine medical situations.
Home Medical Records
Home medical records can be more extensive and inclusive. The more you know about your medical history (and that of your family), the more active role you are able to take in your medical care, and the healthier you will be able to be.
Keep these types of information (in addition to the information already discussed):
Immunization records (both adult and children)
Names of all doctors and health care professionals and their contact numbers
Pharmacy phone numbers
Poison control center phone numbers (find your local poison control center number now through the American Association of Poison Control Centers)
Copies of birth certificates
Test results and medications
It is always a good idea to keep track of any tests such as cholesterol or blood pressure, especially if taking medications related to these conditions. If you change doctors or have a medical problem requiring emergency medical care, it is often helpful for you to be able to provide so-called baseline values. What may be a normal blood pressure for some can be markedly abnormal for others. It is also helpful to have a history of these values to judge the effectiveness of new or different medications for yourself.
Although the most important information to keep on hand are your current medications and doses (and medical allergies/adverse reactions experienced), it certainly would be helpful if you track past medications. This is very useful if you change doctors. There is little utility in switching to a medication that you have already tried and found not to work. Obviously, new doctors would be unable to know about past treatment failures if you were unable to provide them this information.
If you see different doctors, it is crucial to make sure each knows all of your medications. You can avoid dangerous combinations of drugs that have been prescribed by various specialists. This is especially important when you take certain medications for depression and anxiety. If you use one pharmacy to have your prescriptions filled, your pharmacist can give you a printout of all your medications and check for potential interactions.
Store your medical records at home
Handheld personal assistant software interfaces with your home computer, allowing for storage on your home computer’s hard drive.
The websites allow maintenance of records online and also provide options for printing hard copies. There are also a number of other computer-based options, including spreadsheet software and record-keeping software.
For those people without computer access, the simplest thing would be a file cabinet with folders for each member of the family. That way all of the important records would be in one place and would be easy to access if needed. Paper copies of the important records are possible, and duplicate copies would be a good idea.
Special circumstances: The elderly
People who live in nursing homes and other senior-living arrangements are usually monitored by medical staff where they live. If they come to the emergency department, copies of their medications and health histories should be sent by the facility. This is very helpful, especially when the older person has underlying confusion or memory loss and cannot give a history of the problem.
It is especially important for the older person to carry a limited medical history with them at all times. At the very least, they should have contact information for how to obtain their medical information.
People living alone present a different challenge. For emergency medical personnel to be able to locate medical records in a timely fashion, the older person should keep these on them at all times, perhaps in a wallet or something else that is always in their possession. (Posting this information on the inside door of their apartment or room is a practical solution.) MedicAlert bracelets are one helpful solution, but these are not sufficient to include all of the important information. It is up to each person to make these records easily accessible.