Keeping track of everything that has been done is tough for both the doctor and the patient when you’ve been to a bunch of different doctors and had a bunch of different tests, different, treatments, and different diagnoses.
Today I’d like to suggest a way for you to keep your own medical records in a way that might make it easier for you and your doctor to keep track of everything that has been done when you have a long and complicated medical history:
Keep your own medical log.
In the medical log you list in chronological order all your doctor visits, all your prescriptions for medicines, all your medical tests (blood tests, scans, x-rays, other medical test like an exercise stress tests or pulmonary function tests), all your surgeries, all your medical procedures (for example, colonoscopy or cystoscopy).
A person who has a complicated medical history quickly accumulates a mountain of records. So when the patient goes to a new doctor, especially if he is in a different group or works for a different hospital than previous doctors, he probably won’t have access to the electronic records if any.
So if the patient has prepared for the new doctor’s visit, he will have with him a mountain of paper records of his medical past. There is often no way for the doctor to get through all that. And even if he could he would have to do it every visit, as there is no way to remember everything that has been done.
So the patient understandably gets frustrated because often a new doctor will suggest a test or treatment that has been done recently even though it is in the complex record
Now, many electronic medical records can easily organize a complex medical record so the doctor can tell whats been done. But that doesn’t help if you go to a lot of different doctors who are employed by different systems whose electronic medical records are all separate. And so the doctor is forced to work with a pile of paper.
The medical log is a way to organize the information on paper so that a doctor can easily and quickly get a mental picture of your complex health history.
Here’s an example of a medical log (after the example I’ll talk about it and how you can make your own)
Medical Log of Mr. Roberts
9-10-09: Visit with Dr. Smith, FP
9-11-09: Lab tests—CMP, CBC, U/A, Lipid Profile, Free T4, TSH
10-2-09: Visit with Dr. Smith, FP
10-2-09: Prescriptions filled—Lipitor 20 mg once daily, Zoloft 50 mg once daily
11-4-09: Lipid Profile
11-5-09: Visit with Dr. Smith, FP
11-6-09: Prescriptions filled—Lipitor 40 mg once daily, Zoloft 100 mg once daily
1-5-10: Visit with Dr. Jones, neurology
1-7-10: Lab tests—CBC, CMP, ESR, CRP, hemoglobin A1c
1-10-10: Carotid duplex scan, MRI brain scan, echocardiogram, electrocardiogram, 24 hour Holter Monitor
1-14-10: Prescription filled: aspirin 81 mg daily.
2-10-10: . . . .
By just looking through this list, any doctor could quickly figure out what Mr. Roberts doctors were concerned about and what they were working on. There is no problem list or diagnosis list on this log because it focuses on what has been done in terms of treatments, visits, etc. By just scanning this log doctors would identify that the patient was being treated for hyperlipidemia and depression.
Any doctor reviewing the log would also note that the neurologist was concerned that the patient might have had a transient ischemic attack (TIA). And a reviewing doctor would surmise that the neurologist thought it unlikely that Mr Roberts had had a TIA and (because the pace of the evaluation and treatment suggest that some result surprised the neurologist and led him to go ahead and treat for TIA).
Further, a reviewing doctor would infer that Mr. Roberts had had no symptoms suggesting irregular heart beat (because the neurologist ordered a Holter Monitor but not an Event Recorder).
If you have a complex medical history and have created something like a medical log, please share your experiences. Did your doctors find it helpful or not? Was it very hard to keep up? Are there any open source computer programs that you’re aware that might make it easier to create and keep up the log.