Keeping a Medical Journal/Binder
How To Keep Your Own Medical Records And Why
If you have chronic disease and see multiple doctors, it's really important not to assume that all your doctors are communicating information to each other. You are responsible or should be a partner in your medical care. So what should your responsibilities be? What can you or your caregiver do to make sure that each of the physicians in your life has the most amount of information to help you navigate your health issues ? Here are some suggestions for you to consider to make it easier to navigate around different medical offices and clinics.
By law, you have the right to copies of all your medical records. Having said that, facilities have the right to charge a fee for making those copies. If you are unable to go get your reports and information, most facilities will honor a request by you to give a caregiver that information, if you put in in writing and date and sign the request. Either you or your caregiver will need to show photo ID in order to get that information
Another reason to keep a medical journal is that if you need to apply for long term disability or social security disability, you need documentation to prove your case. Having all the information at your fingertips makes it easier to navigate the system
How I Got Started Keeping My Medical Journal
Three-four years ago I was diagnosed with an autoimmune disease in my liver. Besides my general practice doctor, I wound up with a gastroenterologist. Then I added a surgeon specialist for about a year. I dropped him and wound up with a hepotologist. Then after some additional issues, I added a rhumotologost. Then there is the cardiologist that 1 see currently once a year. One doctor I see every three months, The regular doctor as needed and the rhumotologist, I have seen twice. Most times one or the other orders blood work, x-rays or ultrasounds. But I can's always guarantee that each of my doctors gets the reports that the other one orders. So, I started keeping a loose leaf book with all my information. That way, all of my doctors get all the information.
What To Keep In Your Medical Journal
Your medical journal should be very personalized to your needs. But there are a few things that it should have common to everyone
- Basic Information- Name, birthdate, height and weight
- Your Baseline Numbers-Blood Pressure, respiratory rate and cardiac rate
- The names, phone numbers and faxes of all your physicians. I like to grab one of their cards and place it on this page. That way if one doctor has to relay information to another, you have that information at your fingertips
- The names and doses of all your medications, including any over the counter medication. That would include all of your over the counter vitamins and supplements. Every time you have an appointment with any of your doctors they will ask you for an update. If for some reason you have to go to an emergency room, that information will be available. Include the name and phone of your pharmacy.
- history of all your surgeries and procedures This is especially useful when you are seeing new physician
- Any Condition Or Diagnosis- What have you been diagnosed- condition or disease and when
- Any Allergies to medications or otherwise
- Blood work results In my case I go to multiple doctors and it's important for each of them to be on the same page with all my results, so I keep copies of my blood work available when I go to my doctors. One word of caution on this one. Be careful not to read to far into the results of your blood work. Instead, have your physician go over the results with you and explain to you the meaning of them. They are the ones best to define what is important and what is not.
- Any radiology reports It's important to have that information in case your physician wants to know the last time that you had a particular test. If you have received copies of xrays, cat scans or sonograms, keep them also. Another facility may want them to compare
- Any Pathology Reports
- Your Family History- It's important for any of your physicians to know what kind of diseases or histories your family had
- Immunizations or Shots- You should include any immunizations that you have had, or any shots like the flu shot, pneumonia shot, ect.
- Hospitalizations- Include dates and location and why you were admitted
Keep a current list of all the medications that you have to take. Keep extra copies handy just in case you have to get medical help to your home. They will ask you for a list of your medications first thing
Your Job Is To Be Truthful
This information is for you and your physician.Your doctor will make diagnosis, order tests and medications based on the information that you give and his examination. So it critical to your care to be totally honest in the information that you give him. Being a partner in your health care means that you and your doctor have a relationship of honesty and trust.
Your Symptoms-How Are You Feeling
It's important, especially when you have a chronic condition or illness, to advise your doctor about your current symptoms. He/she is not a mind reader and omitting that information may cause the doctor to consider a different treatment plan. Let them know the main things that you are feeling, especially if what you are feeling has changed or gotten worse
Write your Questions Down
Have you ever left a doctors appointment and realized that you have forgotten to ask him a specific question? I know that I have. Write down your questions so that you will remember what you wanted to address with him. It makes life so much easier
Free Printable Medical Journal Forms
How To Set Up A Journal/Medical Binder
How I Keep My Medical Journal
I keep my medical information in a loose leaf binder. I have made sections that work for me. I keep one years worth of reports. I have my medical history, medications. family history, and other records all together. It's very simple to create a binder with the sections that apply to your situation. After the year ends, I place that years tests and reports in a folder in my desk for future reference.
Some people keep their medical journal separate from their binder. I prefer to keep it all in one location.
Caregivers Should Keep A Medical Journal
What if you are a caregiver to a spouse, a parent, a child or some other adult in your family? If you have been given this trust then it is really important that you have access to all the health information that will help you make decisions and guide the person that you are caring for in order to help them or make medical decisions for them if the case comes to that point. A medical journal is a tool that will help you navigate through the system.
Try to have a conversation with the person you are caring for so that you know how they feel about end of life decisions. Make sure that you understand , if possible, what their wishes are with regard to medical decisions. You will also need to know if they have documents like a living will or a do not code order. Know who the health care surrogate is, if you are not the person named. The health care surrogate is the person who is named to make medical decisions if the person is unable to speak for themselves. Get a copy of these documents and keep them in the journal of the person you are helping. Never assume that the hospital or health care facility has these on record.
Make sure that you are with the person you are caring for whenever they see their doctor if possible. Ask them to give the physicians involved in their care permission to speak to you in their behalf.
Having the medical journal for those you are caregiver to will help you navigate the medical system easily. It will help you care for those you love and make it a less stressful situation.
More and more physicians are turning to patient portals as a tool to communicate with patients. They also contain some information as the physician provides access to whatever they ant to use the tool for. Some will allow you to make appointments and request medication refills. Some will allow you to ask a question through an email. Others will show you test and lab results. They will also show statistical information about you. Some will also show clinical information from your visits. It's important to spend some time understanding and learning to use the patient portal that your doctor provides.
Medical Journals Are Important When Filing For Disability
If you have a chronic illness that becomes debilitating, medical journals will help you document the reasons that you are unable to work. Charting your progression with your illness as well as how your illness has effected your ability to work will be helpful information if and when you have to apply for disability