In this era of instant communication, isn’t it ironic how poorly medical professionals communicate with each other and/ or their patients?  It’s an all too common scenario for patients to have lab work done because they are feeling under the weather, only to hear from the office that they have had the infection from the 2 weeks prior when they had the labs intially taken, all the while their health deteriorates. Patients will visit a specialist, then return to their primary care MD a month later—and he still doesn’t have the assessment from the specialist. 

Many patients are elderly , and getting to the doctor in the first place is a chore.  It is really aggravating to make the effort—only to find out that the visit was a complete waste of time—and they had to pay for it!!!!  The only rationale given is that “the office must be really busy”.  Sorry, but that just doesn’t set well for the rest of us—we are busy, too!

One suggestion that I have found to be very helpful is to create your own medical record. To begin compiling a home medical record, contact your doctor's office or the medical records staff at every facility where treatment has been received. Ask for an "authorization for the release of information" form. Complete the form and return it to the facility as directed. While most facilities charge a fee for copies, be aware that legally this fee can include only the cost of copying (including supplies and labor) and postage, if you request the copy to be mailed. If you decide you'd prefer an explanation or summary of your records instead, you can be charged for the cost of preparing one.

You will need the following to do this :

One 2 inch, 3 ring binder

Index tab pages labeled:

General info: Your name, address, phone number, social security number, date of birth; hospital preferences; ambulance preferences; MD names, addresses and numbers; pharmacy location and phone numbers; insurance information/policy number; emergency contact information; names and numbers of loved ones / next of kin, blood type.
Advanced Directives: Tthis may include, but is not limited to a copy of your Health Care Surrogate, Living Will, Five Wishes Form, Do Not Resusitate, Durable Power of Attorney.
Medical History : All diagnoses that relate to you, surgeries and dates, hospital stays and dates, parents age at time of death and cause of death – same for siblings, immunization records.
Diagnostic test results:  labs, MRI’s, CT scans, x-rays, mammograms, cholsesterol level, urinalysis, complete blood count (CBC). Remember that the actual films are maintained in the radiology department, but you can request the written report of the diagnositc test.
Medications / Allergies:  Put the Allergies as the first page with medication lists behind it.
Physician visits: Chronological order with most current visit on top. Include any physican orders for new medications, diets and treatments. If you have had any consultations by speciality doctors, you may want to incluide the advice of the other MD’s so that your Primary Care Docotr can reference that information. This may include an opthamologist, dentist, etc.
Copies of your medical records: Request them from all medical professionals and hospitals that you have been to in the past 10 years.  Doctor’s like to compare current tests to past test results.
Therapy notes:  Ask your therapists (PT, OT, ST) for copies of their notes or at least evaluations with the discharge summary.
Discharge Summaries:  This information would be relevant to a recent hospital or nursing home stay. It would discuss the reasons for admission, significant findings from tests, and procedures performed, therapies provided, condition at discharge, instructions for medications, activity and follow-up care.
Correspondance:  copies of all letters sent and received relative to your medical issues.This may also include copies of consents for admission to a hsopital or nursing home, treatment, surgery and release of information.
Insurance Information:  This may include claim forms received by mail, changes to your current policy, a creditable coverage letter with regard to Medicare Part D.

Plain paper fax machine (~$50 – serves as a copier and a means of communication).

Keep blank physician visit and medication list forms at the back of the notebook. (Please visit our web site for a Physican Visit and Medication templates: www.elderadv.com)   Each time you go to the doctor, complete a Physician visit form and file it.  This will help you to keep track of who ordered what and when.  Ask your MD to always fax you your lab and diagnostic test results.  File them. 

Keep your medication list updated.  It’s recommend that you indicate by calendar date and highlighter when a medication was discontinued, and what is was replaced by, if appropriate. This way you don’t have to keep re-writing the list each time there is a change.  The medications that are not highlighted are your current meds.

Be sure that you take this medical record with you whenever you go to a medical appt.  Make sure that loved ones know about it and where you keep it should you have to go to the hospital in an emergency.  This tool becomes invaluable to keep communication flowing from one medical professional to the next.

Elder Advocates Incorporated | 407.898.9080 | www.elderadv.com