Family Medical Records

The personal medical history, as recorded in the medical record, can play a central role in evaluating patients in a variety of medical settings, particularly in emergencies. When doctors evaluate patients for any medical issue or complaint, easy access to the medical history of the patient helps the doctor provide more efficient, accurate, and appropriate care and to minimize unnecessary and costly tests.

Having personal medical information readily available can be particularly important in the following situations:

• During a visit to the emergency room
• Going to urgent-care centers
• Being evaluated before a surgery
• Visiting a new doctor or a specialist for the first time

Having current personal and family medical records can be even more important for people who themselves are unable to provide their medical history adequately, such as children and the elderly.

With the advancement of electronic medical records (EMR) or electronic health records (EHR) in recent years, medical information is more easily accessible by health-care professionals. However, it is still important to carry one's own medical records. A few of the many reasons for this is the following:

• Records from one hospital may not be accessible by another hospital.
• Records from one medical office using one EMR system are not accessible from another medical office using different system.
• Authorization for release of records is still required for obtaining medical records from another doctor's office or medical facility.
• Lists of medications frequently change during outpatient clinic visits, which may not be available to another clinic or emergency room.

Why should I have to keep this information?

Personally carrying one's own medical records has many benefits when receiving medical care.

In many situations, especially in emergencies when a patient may be unresponsive or otherwise too ill to adequately provide information verbally, knowing the past medical history becomes vitally important in initiating the correct and timely course of evaluation and treatment. Additionally, this information can significantly diminish the chances of repeating tests and subsequently reducing health-care costs.

Patients often arrive at hospitals without any information about their medical problems. This presents a difficult and sometimes potentially dangerous situation. Although the tests and medicines that 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 or unnecessary test. Additionally, many of these tests are time-consuming and can delay important treatments. If an individual carries his/her own medical information for the doctor to review, it can allow the doctor to save time and provide care more effectively and efficiently.

It is also important to realize that in many emergency situations, a patient may arrive with inability to talk or may be unconscious, and evaluation and treatment need to begin promptly before the patient's condition further deteriorates. It is not uncommon that no one familiar with the patient is available to assist with providing medical history. Even when a family member, friend, or caregiver is available, they are often overwhelmed by the situation and unable to focus in order to give the necessary information.

Beyond the need to provide appropriate care is the importance of contacting family, friends, and other physicians who may know valuable information about a particular patient. Not only can these people provide important information, but they also can offer much-needed emotional and decision-making support for the patient. Having the ability to contact families early in a patient's care can help simplify very complicated and challenging situations.

Emergency medical care can be life-saving but is often filled with difficult and expensive decisions that must be made rapidly. Maintaining one's own records is one of the best ways for someone to take an active role in his or her own health care and to ensure that he or she receives rapid, effective, and safe treatment in both emergency and routine medical situations.

Availability of personal health records is crucial even in nonemergency conditions. For example, visiting a new physician in the office can be stressful for a patient and he or she may not remember all the facts about their medical past. They also may not know how much of the information is pertinent. Although the doctor goes through a series of questions methodically, a patient may not be aware of all the facts that are important to the doctor.

It is true that primary-care physicians or family physicians often have the most current and comprehensive health records for their patients. However, to rely solely on the family doctor to be available all of the time and be able to locate the records instantaneously is unrealistic for these reasons:

• Emergencies can happen at any time -- day, night, weekend, and holidays -- and one's personal doctor may not available all the time.
• A medical release form has to be authorized by the patient individually or by patient representative for another doctor, a specialist, or a facility to receive this information. This process is time-consuming, and it may take days or even weeks; it is usually associated with out-of-pocket administrative cost.
• A patient may see multiple physicians for different health conditions, and it could take the family doctor some time to receive all the medical information from the consulting physicians.

In ideal situations, a patient will be able to answer a doctor's questions during the visit. However, very often, many of these questions are left unanswered or incorrectly answered. Some of the common reasons for inadequate patient-doctor communication are the following:

• Stress and anxiety of an emergency situation
• Nervousness about seeing a new doctor
• Unresponsiveness or unconsciousness
• Being too ill or confused to communicate effectively
• Patient's or doctor's time constraints
• Not knowing the correct information about medical diseases or medications
• Being without relatives or caregivers who can provide or assist with the information
• Language barrier
• Not remembering all of the medical history or not knowing what part of past medical history may be important to the doctor

When doctors take a medical history from a patient, they typically go through a structured, routine set of questions that are combined with their examination and diagnostic information to help them to make medical decisions.

Other than questions pertaining to a presenting symptom or complaint, doctors usually want to know previous medical problems, recent hospitalizations, chronic (long-standing) diseases, operations, current medications, allergies or intolerances to medications, social and occupational history, medical problems of family members, name of the primary-care or family physician, and the date of last visit to the doctor.

Essential medical information will be different for each person. Although it may not seem relevant, knowledge of even the smallest medical detail could potentially provide critically helpful information. Keeping an up-to-date and concise health record for oneself and family members is strongly recommended for everyone.

It is a good idea to have a more complete list at home and more brief copy, ideally on one page, with you at all times. Nowadays, many people have a document for their personal health history on a home computer and they can easily update it after each doctor or hospital visit. They can then print this document and have it handy and available for unexpected medical situations. There is also computer software available that can keep and organize family medical records.

Some of the essential personal health records that should be kept in one's permanent file at home may include the following:

• Major medical problems: 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, cancers, strokes, heart attacks, ulcers, etc.
• Other medical and surgical history: list of any illnesses, hospitalizations, or operations you have had. This list should be comprehensive and should include a history of cigarette smoking history, alcohol consumption history, sexually transmitted diseases, serious infections, and major or minor operations, and mental-health disorders.
• Childbirth: Women should add a history of childbirth, including miscarriages, abortions, and cesarean sections as well as natural births and even adoption history.
• Current medications: a comprehensive list of any current medications with dosages and frequencies (how often taken). Medicines such as blood thinners, water pills, blood pressure pills, antibiotics, and antiseizure treatments have important interactions with one another and other drugs. 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. 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 and significant food allergies (peanuts, shellfish, etc.). Some people have very serious allergies to common medications. It is essential for doctors to know this information when treating people. When known, the precise type of allergic reaction should be listed (itch, rash, hives, difficulty breathing, swelling, anaphylactic, or near fatal experience, etc.). Intolerances to medications are also important to note (such as nausea, vomiting, abdominal pain, headache, confusion, etc.).
• Family medical history: history of high blood pressure, heart disease, diabetes, blood clots, cancer, and other conditions in blood relatives. This history can affect how you are diagnosed and treated. Most important are the histories of parents, siblings, and children, but medical information about other family members may be pertinent as well.
• Phone numbers: phone numbers of family members, treating doctors, therapists, pharmacist, or other health-care professionals. Each of these professionals can provide valuable information and can be very helpful during emergencies.
• Medical data: Some medical data are also important to have in personal medical records. Some examples include any abnormal laboratory tests or examinations (blood counts, kidney and liver functions), heart catheterization and stents, pacemaker, chest X-ray, etc.
• 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 above 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.
• Advance directive, power of attorney for health care: It is very important to have legal documents in place stating whom they designate to make decisions for them when they are unable to do so themselves and what their wishes may be. Frequently, family members and doctors are left with very difficult life-and-death decisions to make about patients who are in a condition where they are incapable of making decisions about their own care (confused, unconscious, on artificial breathing machine, etc.). By having prepared these documents ahead of time, the burden of decision-making is lifted from family members in these tough situations and, more importantly, the patient's wishes are respected. The power of attorney for health care can make decisions based on what they know the patient would want in a particular situation. Typically, your primary doctor can guide you in this process. These are legal documents and are generally filled out with the help of an attorney.
• Individual's decisions about end-of-life decisions and physician orders for life-sustaining treatment (POLST): Each individual may have a different view as to how they would want to be treated in critical medical situations in terms of heroic measures and artificial means to sustain life (placement on a breathing machine, performing CPR, artificial feeding, etc.). POLST is a new form which first became available in Oregon in the 1990s, and now it is available in many other states. This is a single page in a bright color that is filled out by the patient and signed by their doctor. It addresses the patient's specific wishes for particular clinical situations where life-and-death or life-sustaining decisions may be necessary. This form, or a copy of it, should be carried with the patient at all times.

How should I carry and store all of this information?

It would seem impossible, even impractical, to carry all of this information with you at all times. Fortunately, there are a number of reasonable alternatives to carrying a photocopied medical chart.

• One-page summary: The simplest, and arguably the best, way to have immediate access to personal medical records is a one-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. This one-page history should include the most critical information that will be useful in an emergency and also easy for a doctor to get a quick idea of your personal health information in a non-emergent circumstance. This page should include the following:
  • Name, address, home phone number, and date of birth
  • Name and contact of primary-care physician
  • Name and contact information of the next of kin or the best person who can provide additional health and personal information about you
  • Brief list of chronic medical diseases and previous surgeries
  • List of all prescribed and over-the-counter medication with dose and frequency
  • Medication allergies
  • Health insurance information
  • Name and phone number of the pharmacy
  • Personal wishes in regard to end-of-life decisions (CPR, breathing machine, artificial life-saving heroic measures)
• Electronic medical records (EMR): The Internet provides another option for people to organize their family medical records online. Many companies have developed web sites 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. Additionally, some of the sites are designed to allow doctors access to the information in emergencies. The information is password protected, and some of the sites do not charge for their services. These online electronic health records (EHR) sites are very useful; however, they do not replace the official medical records kept by your physicians and your hospital. They hold the data which you enter in a template and update personally for your own health-care records or for someone whom you care for. Although, there are more and more of these sites being developed, a few of them are listed below:
  • WebMD
  • Family Health Information Manager
  • My Personal Health Records
  • Health Vault
  • Health Minder software
  • HealthIT.gov
• Electronic medical records (EMR) software is also becoming increasingly more available in medical offices and hospitals. One of the biggest advantages of this technology is that a patient's record can be accessed each time they go to the emergency room, hospital, or the physician's office. So long as a patient goes to the same facility, the records could be easily accessed during each visit by their treating doctors. However, it is worth noting that there is a variety of EMR software, and facilities and hospitals often use different programs. Furthermore, if an individual presents to different hospitals, obtaining information from another facility has to be authorized by the patient before any medical information can released under the Health Insurance Portability and Accountability Act (HIPAA).
• 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 are 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.
• Smartphone applications: There are currently similar phone applications ("apps") available that can be used for the purpose of storing and organizing one's personal medical information. Many medical records apps exist for smartphone (iPhone, Android, etc.) devices, some of which charge a fee while others are free of charge.

The one-page personal health history is often preferred because it can be accessed most easily in an emergency situation and is carried with the person all the time. Invariably, these electronic personal health record web sites require a password for your personal protection. Thus these health-record organizers could be difficult to access by health-care personnel if the individual is unable to log in. Oftentimes the medical staff may not know if a patient has one of these services online. A summary can even be printed from some of these programs to be carried around and readily available.

As mentioned in the previous section, useful and quick reference to personal medical records can be done most efficiently and practically on a single page, ideally printed or legibly written, to include the following information:

• Name
• Home address and telephone
• Date of birth
• Emergency contacts (family members, neighbors, or friends)
• Physicians' name and contact information
• Drug allergies
• Current medications with doses and frequencies
• Chronic medical conditions (for example, diabetes, high blood pressure, previous strokes previous heart attacks, asthma, ulcers, etc.)
• Past operations
• Medical insurance (health plan, phone numbers)
• Pharmacy name and phone number
• Advance directive, durable power of attorney for health care or POLST form (to designate another person for situations when one is not mentally capable of making one's own medical decisions)

More extensive and inclusive medical records can be kept at home. 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.

• 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. 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 web sites 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 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 go to the emergency department, hospital, or to a new physician, copies of their medications and health histories should be sent with them 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 with 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.

Final Words on Family Health Records

• Always keep your personal and family health records updated. If a new medication is added or dosage of a medication is changed, an important phone number is changed, you have seen a new doctor, you have a new diagnosis, or any other changes pertinent your or your family's health, the personal health records should reflect the changes.
• A person close to you needs to know that you have such medical records available and, more importantly, needs to know where they are kept.
• Keep a one-page copy of updated personal health records with you at all times.
• If you have questions about what may be important enough to be placed on your personal medical records, consult with your primary-care or family physician.