Keeping a Personal Health Record

Today everyone needs to manage his or her own health care in partnership with their primary care physician. Staying healthy involves more than calling your doctor when you're sick or injured. It means eating balanced nutritious meals, getting the right kind and amount of exercise and rest, and having a lifestyle that promotes wellness and prevents illness. One important thing that you can do to promote wellness and get the most out of your visits with the doctor is to maintain a personal health record. Keeping a personal health record is a simple process, but it has many benefits. Today there are even software programs that help you keep your personal health record on a PC or on a confidential Internet site (for instance, http://www.capmed.com).

The Value of Keeping a Record

  • Helps you monitor continuity of your health care
  • Records important health information about you, e.g. allergies
  • Helps you better explain any health problems when you meet with your doctor
  • Documents information that may be useful when filing health insurance claims

Information in a Health Record

  • Family medical history
  • Personal medical history
    • Results of your Health Risk Appraisal (you can do a free HRA at http://www.nhlbi.nih.gov/health/index.htm)
    • Immunizations and childhood illnesses
    • Other illnesses, injuries, hospitalizations and operations
  • Allergies to food, medications and other substances
  • List of medications you are taking and instructions for their use
  • Important medical problems, e.g. diabetes or heart disease.
  • Names and phone numbers for:
    • Whom to contact in an emergency
    • Your primary care physician
  • Medical insurance policy name and number
  • Record of preventive care, e.g. mammograms, pap smears, dental exams
  • Important health "numbers", e.g. blood pressure, weight, cholesterol
  • Sample adult and child health information forms may be downloaded from http://www.ahima.org.

Other Documents to Keep in the Record

  • Your health log or diary:
    • Description of symptoms or health problems you are having
    • Dates and reasons for doctor's office or emergency room visits and hospitalizations
    • Written instructions and advice from your doctor
    • What to expect from treatment and when to return to your doctor if you don't improve
    • Side effects or unusual problems with medications you are taking
  • Copies of important medical records, including lab tests, radiographic reports, operative reports and consultation reports
  • Your insurance plan Explanations of Benefits
  • Receipts for your payments for health care
  • Correspondence and personal notes of phone calls related to your health care
  • A copy of your Advance Directives or Durable Power of Attorney
  • If you move, have a chronic illness and/or frequent hospitalizations, or are dissatisfied with your care, you may want to request copies of your medical records from your doctor and hospital.

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