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by Kathryn Kilpatrick
Ever had a doctor's appointment and forgotten to report something that had happened weeks ago, or remember later a question you neglected to ask? In some cases, you may have been given a lot of new information during your appointment and are not sure that you recalled it all exactly, or thought of some other questions once you were home. Yes, it happens to all of us some of the time.
Many years ago, I had a serious medical problem with some additional health issues that arose from my inactivity level from such an extended period of time. What I noticed is that in an attempt to make the most of my visits to my doctors, I needed to keep better track of the symptoms and how they responded to different treatments. There was nothing wrong with my memory, but the stress and the uncertainty as we explored a diagnosis created a situation that required me to do more than rely on my memory from appointment to appointment. Recently, while I was clearing out the basement, I came across those detailed records from almost 30 years ago. As I reflected back on those years, I realized how this personal situation provided me with some of the ideas I now share with others who are trying to provide information to a variety of health care professionals in a way that can maximize their appointment times and health care.
Most of the patients I have seen though the years have been homebound, and the scenarios vary greatly from those living alone at home to those with significant impairments in communication and memory. Having a person unable to recall or provide the necessary medical information during an initial assessment is a frequent occurrence. Even if the caregiver is a spouse or close relative, they may not know or remember all of the medical issues that have occurred through the decades. In some circumstances, it is weeks later that an important piece of information may be remembered, but often, by then, the details have become blurred.
Your Personal Medical Record Summary Sheet
One of my clients had a serious stroke that impaired his speech. Since he had significant word recall deficits, he struggled to answer many of the background questions. Providing any medical history was very frustrating for him and made it difficult for me to do a complete assessment.
His wife was at work and unable to be present for the session. Fortunately I was able to contact her when she returned home that evening, and she provided more specific information that I needed to create my plan of care. My suggestion was that they put together a medical history information sheet and that they keep that in a place in their home for easy access. With this type of information available, this gentleman would have been able to answers yes or no questions about the details with good accuracy, and we could have used that initial session to complete a more detailed language assessment and get started on treatment strategies. With multiple health care professionals evaluating him over the next few days, the information sheet would have been most helpful for all involved, and with updates, can become a key document to take to further medical appointments.
Several years ago I had a woman with swallowing problems who had a very extensive history of physical problems secondary to problems with back pain spanning many decades. She had actually created a list of those problems and written them in pencil on a piece of paper that had been folded many, many times. She was on the right track, but I made a suggestion that took her system to the next level. She now had difficulty printing so I recommended that she have her grandson put the information into his computer and print out several copies. If there were new things to be added, he could put them in the list and print an updated copy. Now, whenever she has an appointment with a new health care professional, she brings a copy of her updated and detailed medical history information sheet with her so that person can review it first, then ask for any additional details that may be essential to the overall assessment.