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Compile a health record for emergencies and to inform doctors

Compile a health record for emergencies and to inform doctors

October 29, 2007|By JULIE E. GREENE

Let's say you end up in the emergency department with chest pains.

If you're conscious you can tell the doctor what medications you take - if you remember them all.

If you're unconscious, hospital personnel might look on your person for a list of medications.

A person in their 40s or 50s with chest pains - there could be a lot of different causes for that, said Dr. Stephen Kotch, chairman of the Department of Emergency Medicine for Washington County Hospital.

Patients who can provide a list of their medications or a detailed medical history can help the medical staff narrow down the likely diagnosis and target tests and diagnostics that should be run immediately, Kotch said.

Everyone should prepare their own health record, according to officials with Washington County Health System and American Health Information Management Association.

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The document, or folder of documents, isn't just for emergencies, said Shereen Martin, privacy officer and director of medical information management for Washington County Hospital.

Many people have multiple doctors, including specialists.

Patients can be better advocates for their own medical treatment if they are more knowledgeable about their medical histories and can share that information fully and accurately with the doctor at hand, Martin said. Perhaps they could eliminate duplicate testing such as multiple x-rays for different doctors, she said.

Keeping health documents together also can be handy if you have an incident when traveling or if a disaster occurs, according to Martin and to Carey Leverett, vice president of information systems for the health system.

The American Health Information Management Association provides health record forms that people can print and fill out; go to www.myphr.com/your_record/free_forms.asp to find the forms. Or people can write out the information long hand, Martin said. Either way, the information should be legible so a medical professional, caregiver or family member can read it in case of emergency.

Emergency situations

Kotch said people should not assume doctors know a particular patient's medical history. Washington County Hospital has a computerized database containing information about patients' past visits, Kotch said, but a person's medical history or medications might have changed since that visit.

In case a visit to the emergency department is required one day, Kotch recommended everyone keep a piece of paper in their wallet or purse - behind the driver's license is best - listing their medications, allergies, hospitalizations within the last five years and chronic medical conditions such as diabetes.

If a person arrives at the ER unconscious and the staff finds a medication list that includes antidepressants, pain medications or sleeping medications, that helps narrow down the possible causes of unconsciousness rather than having the staff spend hours doing lots of tests, Kotch said.

"Computer systems are great, but there's nothing like having that key piece of paper to see information in five seconds rather than log onto a system and sort through information," Kotch said.

At least one local ambulance company provides cards, he said, on which people can list their medications and contact information. Patients post the card on the refrigerator, Kotch said, and emergency medical technicians can grab the card and bring it to the emergency department with the patient.

If people don't know what medications they're on or the amounts they are consuming, they should take a few minutes during their next doctor's office visit and talk to the nursing staff, writing the list on an index card, health-care officials said.

What information you need

How much information people want to keep in their health documents folder is up to them. Generally, health-care officials said, the more health issues people have, the more important it is to have that information handy.

Martin recommended a basic package: a duplicate of the emergency card, which lists medications and allergies; identification information; emergency contacts; insurance providers; medical conditions; and vaccines a person has received.

When making the list of medications, include the name of the medicine, how much you take and how often you consume it.

If a person has had serious health issues and wants to be more thorough, include copies of lab tests and x-rays, attaching results to the relevant health documents so they're easier for a doctor to review, Martin said. Make a note of what the test was for, the date and the result.

People also might want to include information from their dentist and eye doctor, such as their eyewear prescription.

To get a copy of their health records, people will be asked to sign an authorization form allowing the release of the information, Martin said. The form is a requirement due to state laws and the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996, which gives patients more control over how their information is disclosed. Patients might also have to pay a photocopying fee.

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