Retaining copies of our medical records could reduce potential for mistakes.
With all the talk about health care consumerism by human resource and other employee benefit professionals have you ever heard them suggest things other than purchasing health care “in-network” or “sharing the risk” makes employees more responsible consumers? How about some common sense, practical steps that everyone should do. Take control of your medical history and records. Learn what is in them, and protect them against miss use or yourself from potential mistakes. In addition, we here that the government regulators are issuing guidelines and rules that make sense at one level but scare us at another. Yes, then want to take control of your medical records before you even have control of them.
It makes sense to improve medical records so that all your providers who treat you have the same knowledge and information. The assumption currently is you have the information and share it as needed. The problem is, you have either have not taken control of your records, your medical history or you may not be able to transfer that information correctly to the providers.
We all know that childhood game “telephone”, that is what can happen when you haphazardly transfer information. The providers down the line make not be getting the proper message. Personally, when I moved I asked my family doctor to give me a copy of medical file to provider to my new doctor. Well I got a hugh shock when I got a look at them for the first time.
First of all, they were all handwritten, mostly illegible. It looked like he used some shorthand or morse code. There were no records from my pediatrician who was my prior doctor since my family doctor must not have asked for them when I became his patient.
To make is worse, my doctor had passed away earlier that year. Now I could not even get them interpreted. Years of care, recorded in worthless notes.
Everyday you hear stories like mine or like this. A man was scheduled to see a cardiologist for recurrent palpitations. The same symptoms nagged him about six years ago and at that time, he went through a battery of tests to confirm that the palpitations were benign.
Later, he was able to take the EKG and stress test echo results from that episode with him to share with the new cardiologist. Although new testing was ordered, the cardiologist was able to compare the older study with the new study. And he had some peace of mind that there was some continuity in his care, even if the patent had to provide it.
I would encourage all clients with whom we work to get copies of any diagnostic testing or blood work that they’ve had done. You will find that as you see more doctors, the more medical files you have to collect, store and be prepared to share. Common sense should tell you the more scattered your medical records are, the higher your risk of drug errors, missed diagnoses and other potentially dangerous glitches. The solution is simple? Patients should keep a set of their own records at home and electronically stored in an accessible location. I like a one of the USB flash drive. You can lock it for security and store it easily in your backpack, purse, etc.
More commonly will see our older patients who may have typed their extensive medical history on a computer. Whenever they have a new physician appointment, they print out an updated version and takes it with them to the office.
Their records looks something like this:
- Demographic and Insurance information
- Medical History
Since most providers required you to complete all this information the first time you see a new providers just put your name on the form, attach your own printout and return the clipboard to the receptionist. It saves you time, her time and prevents unintended omissions.
Here are the basics on personal health records. They can be paper or electronic. There are a growing number of solutions are available. The American Health Information Management Association provides a step-by-step guide to creating your own personal health records on its Web site, www.myphr.com.
Like all types of data, there are a number of portable storage devices options (CDROM, DVD, USB flash drive or smart phones) and word processing templates also can be used to help create an electronic record. There are a few disadvantages of storing information this manor. Data that is stored is subject to physical loss and damage, paper can be burned, water damaged, as can electronic records and many computers at your providers’ offices and hospitals cannot read or update your records. One tools I would suggest you add is a scanning device. You can take your then take any document and scan it and store it in your electronic health record folder.
Suggestions for Employers
Many companies that offer health promotion (or wellness) programs are also are instituting incentives to encourage their employees to complete health risk assessments and create personal health records as a way of tracking changes in risk or detecting improvements.
By providing employees tools to monitor their health, some companies are think they can cut health care costs without triggering worries about health data privacy. Since knowledge is power, an empowered employee is a likely to be a healthier employee. Health records are a great tool for helping employees take personal responsibility and make smart decisions related to trends in their own health.
To encourage your employees to maintain their own personal health records, you can advise them to:
- Ask for results. Request a copy of all blood work or test results along with a a copy notes from all examinations performed by the provider. Don’t be surprised if you are asked why you want them
- Collect records from your dentist, pharmacy, hospital, lab and any other facilities
- Keep paper in a brightly colored folder so they’ll be easy to spot in an emergency. For added protection, keep one copy of the records in a safe deposit box or other safe location along with other important documents like Wills, Deeds etc.
- Organize the information in a way that makes sense to other people. Use standard indexing or logic
- Always carry a mini-record that identifies your key health care providers, an emergency contact number, the names and dosages of any medications and alerts to any allergies you may have
- Bring and review your personal health history with your primary care provider durning your periodic examination. After all, now that you have this complete health record, is it a good idea to provide your primary care physician or nurse practitioner with a copy?
Since it is estimated that only 7% of patients actually put together their health records your doctor should be pleasantly surprised.
Take Control – Take Responsibility
No one knows what future holds and recent health care reform laws has only increased the level of uncertainty, but one is certain, errors in communication resultant to a poor exchange of information or the lack of adequate information will continue. Health care is a people centric process and people make mistakes. Test results will still not make it to the chart. Consultation letters skipped. Allergies will be missed. Medications and their dosages will be prescribed incorrectly.
Make sure that you are in control of your own health care information. Encouraging your fellow employees to collect and maintain their own personal health record. It may save your life or protect your rights to privacy.
Here is what you should include in your a personal health record:
- Personal identification
- Emergency contacts (including telephone numbers)
- Health care provider contacts (including specialists, dentists & pharmacists)
- Health insurance information (including Plan Sponsor, Policy / Group Number & contact telephone numbers)
- Living will, advance directive, or power-of-attorney
- Organ donor authorization (if any)
- Current medications and dosages
- Significant illnesses and surgeries (including dates)
- Record of immunizations (including dates)
- Allergies or other sensitivities
- Results from most recent physical examination, including eye and dental
- Test results
- Family health history
- Opinions of specialists
- Correspondence with physicians
Related Wellness & Health Sites
