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patient rights

Improving Patient-Physician Connectivity: The Personal Medical Record
Improving Patient-Physician Connectivity: The Personal Medical Record If patients can assist physicians by making it easier to obtain a medical history in a physician friendly format, it’s a win-win opportunity.

Most patients overlook one of the most important benefits you can give yourself to ensure high quality personal healthcare. For any physician, the very first necessity before identifying and finding solutions for your medical needs is obtaining an accurate medical history of both current and previously established medical problems. Providing your physician this critical information in an accurate and consistent manner improves efficiency by allowing your physician to spend more quality time with you, and it differentiates you from other patients allowing your physician to hold you in higher esteem, which makes your care safer. It could even save your life.

Medicine today is increasingly more a “business of healthcare” than a practice. Time constraints driven by the physician’s need to see more patients in a shrinking reimbursement environment has resulted in rushed visits that are less satisfying to both patient and physician. If patients can assist physicians by making it easier to obtain a medical history in a physician friendly format, it’s a win-win opportunity. However, giving your physician too much information may have a paradoxical effect. Patients who bring volumes of paperwork about their history cause physicians to suffer from “terminal information overload” and may overwhelm the amount of time a physician can reasonably allot gathering information. Unless your physician specifically requests extensive medical records on your behalf, chances are they will not want to sift through reams of paperwork to find answers to the basic information they really need. Your doctor doesn’t want to read the whole book; he or she is much more interested in getting the “book report” version.

“Chief Complaint” (CC)
When my patients have seen this essential bit of information described as the “chief complaint,” they have told me “but I don’t want to be a complainer!” Don’t worry, physicians do not see the “chief complaint” in a negative light, rather the quickest way to express your answer to, “So what is the problem you’re having that has brought you to see me?” Whether your doctor has seen you, a hundred times, for the same problem or it is a new problem CMS and other third party payers demand documentation of the patient’s “chief complaint” or they can refuse to pay the physician for the visit according to “documentation guidelines” established in the 1990’s. Give your physician your “chief complaint” as a simple, short sentence that describes the reason, or a symptom that brought you to see your doctor on this particular visit. Simply saying, “My head hurts,” or “I’m here for continued treatment of high blood pressure,” is all that is necessary.

“History of Present Illness” (HPI)
To explore the types of diagnoses that may underlie your “chief complaint,” physicians typically will ask a series of questions about the nature of the problem. What is the location of the problem on your body? If there were a way to describe the quality of the symptom(s) you are experiencing, what would it be? How severe is the problem to you? How long have you been experiencing the problem? Does the problem occur at a specific time or in the context of an activity? What factors modify the nature of the problem? What makes it better or worse? Are there associated signs or symptoms with the problem you’ve been having? If you have chronic and/or multiple problems that your physician may be aware that are not necessarily related to your “chief complaint,” what are the status of these problems?
Here is an example of the type of information physicians look to get from a patient.
CC “I’ve been having problems swallowing.”
HPI. For the last two months (duration), I’ve noticed a sticking sensation (quality), in my chest (location) during meals (timing). I haven’t had any problems with liquids but it happens with solids (modifying factors). Chicken is especially bad (modifying factor). It goes away on it’s own but sometimes it aches a little and feels as if the food hangs up before it passes (quality). I ’ve noticed I have had more heartburn recently (associated sign/symptoms) and I’ve been taking antacids and that helps with the heartburn (modifying factor), but the swallowing problem has been getting worse (severity). It’s bad enough so I avoid ordering meat at restaurants (severity). My blood pressure and diabetic blood sugars haven’t been giving me any problems (status of chronic problems).

Accompanying the information shared about an acute problem would be a brief listing of “past medical history,” “family history,” and “social history.” This information helps a physician place your current problem in context with your overall medical history and alerts your physician to issues that may need attention in conjunction with or in addition to your current problem.

“Past Medical History” (PMH)
What medications do you currently take or have previously taken? Drug interactions are more common than you might imagine and could even be responsible for your presenting problem. Do you have any medication allergies? This information could literally save your life by avoiding a severe allergic reaction. What previous significant medical problems have you had diagnosed? Is your treatment up to date? What previous surgical procedures have you had? These basic bits of information may lead a physician to further questions or a request for a more complete medical record.

“Family History”
What are the significant medical histories of your immediate relatives? How old are your parents or what was their age at death? What medical problems did they have and how could they relate to your own medical history, either by genetics or shared environmental factors? Again, a simple synopsis is best. “My mom is 73 and in good health except for a little high blood pressure and my dad died when he was 68 of lung cancer. I have sisters aged 49 and 50 and they are in good health except my oldest sister had breast cancer. My children are 17 and 19 and they’re healthy.”

“Social History”
What kind of work history do you have? Have you ever been exposed to chemicals or other hazards from employment? Do you smoke? If yes, for how long and how much per day? Do you drink alcohol? How much? Do you use “recreational drugs” that must be factored into your overall treatment? What kind of educational background do you have to make sure communications are clearly given? Are there social or family problems that may be contributing to your medical problems or may interfere with treatment?

While these factors only scratch the surface of a complete medical history, it gives physicians instant access to basic elements that they must have as a foundation before exploring with more detailed questions to help treat you in the best way possible. When you document this information in a useable, convenient way to share with your physicians as well as other healthcare professionals, you accelerate the diagnostic process and your eventual treatment. And when you have personal control over this critical information, you can enjoy the benefits that a “Personal Health Record” can afford you.

“Personal Health Record” (PHR)
In an increasingly fragmented healthcare delivery system, it is rare for any one hospital or physician office to have a complete medical record. The time invested to create a PHR will pay handsome dividends in not only emergency situations, especially if you are incapacitated from giving a personal history, but also in routine visits to new physicians and healthcare professionals in an office, hospital, or emergency room setting. Being able to produce a complete medical record on a first visit to a new facility may save you the time and expense of having to schedule a return visit after your physician obtains records that your memory alone couldn’t provide on your first visit. Moreover, it lets your doctor know you are proactive in your own care because you are in charge of your own healthcare as much as you can be without going to medical school! Informed, helpful patients who are aware of what helps physicians do their job better and more efficiently are not common in a medical practice. Speaking from my own personal experience, the rare patients that can provide an accurate, up to date, concise, synopsis of their current problem and previous medical history are demonstrating an interest in saving me time. In the face of shorter patient visits, by providing your physician information proactively gives doctors more time to answer patient questions and get to the heart of the problem faster.

Personal health records exist in a number of formats, each with their own advantages and disadvantages. The ideal PHR can be easily updated and be used anywhere, anytime. Web-based systems are convenient but require web access and electricity! At times of civil and natural disasters, this may not be possible. Paper based systems require easy access and unless carried at all times may not be readily available. Smart Card or similar media storage can be a hassle to update and may require a specific reader a doctor or facility may not have access to, but is very convenient to carry. A software program is easy to update but requires a print out to be brought to visits. Perhaps a hybrid system would be best.

More information on a PHR as well as a listing of paper based, web-based, computer software, or other media based systems are available on a website maintained by the leading organization of health information management, the American Health care Information Management Association, (AHIMA). You can find the web address of the AHIMA at www.radthemag.com. Just click on the Patient Rights link and go to this article. There you will find information about an additional site that offers free downloads of templates for both acute physician care visits as well as a simple “at a glance” outline for essential past medical history emergency information. Whatever your ultimate choice of a PMR is for your own or family’s use, having a PMR is an inexpensive, sensible, and prudent way anyone can help make their own medical care easier, more efficient, and safer. It’s a simple solution no patient should be without.

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"Improving Patient-Physician Connectivity: The Personal Medical Record"
   authored by:
SURGERY
Dr. Dunaway received his MD from the University of Pennsylvania and his post-graduate work in general surgery was completed at the University of Virginia and the University of South Alabama. He is a board certified surgeon and a Fellow of the America...



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