patient generated 5-minute medical history

By | Fri October 6, 2017

While I was out hiking today, I got to thinking – thinking about one of the challenges I face with complex medical conditions. One of the problems I run into is that I get so used to things as being ‘normal’ that I forget to include them in my medical history. For example, I have celiac disease. I’ve been gluten free for over a year (yay). I’ve gotten used to the idea of being gluten free. It has become normal for me. So when I’m at a specialist, I don’t necessarily mention it. When I was at the ophthalmologist, I didn’t think to mention it. I have sleep apnea (well really hypopnea – a side effect of my cancer surgery), and I forget to mention it. I forget to mention that I’ve had lymph nodes out on both arms such that I cannot get IVs in both arms. I forget until it becomes very relevant (like when an anesthesiologist is wants to put an IV in my arm).

Throughout my cancer experience, I have learned that I need to be my own advocate. One thing I like to say is that I’m my continuity of care. I am the one variable that does not change regardless of which doctor I’m seeing. Doctors are busy. They see a lot of patients, with a lot of different issues, and yet we expect them to both be experts in the disease they are treating, but also understand our full and complete medical histories. And yet, there isn’t time for that in a typical interaction. Specialists in particular have tunnel vision. That is what makes them specialists – they get one thing very well, but they do not necessarily get complexity. I actually talk a little bit about this in an article I wrote for In-Training – where the resident wasn’t willing to admit she didn’t know about breast cancer – I was at a sleep clinic, I didn’t expect her to know, but I did expect her to admit she didn’t know, so that I could give her details that might actually be relevant to why I was at the sleep clinic.

Medical students and residents learn to take patient histories. They learn to go through a script asking all the questions they believe are relevant. As I patient with complex medical issues, I often find that is exactly the situation where I forget something – which might not matter, but might also be rather significant. It is with that, that it occurred to me that as a patient I should spend some time creating a patient generated 5-minute medical history – maybe a two page written document that summarizes my issues. That isn’t a lot of space – but it doesn’t need to be. It needs to say the most important parts about diseases, current medications, and any major past medical treatments.

This could go a long way to ensure that I don’t forget something important. It doesn’t replace the patient history / interview that the doctor does – it just provides a more wholistic view of my health – something that a specialist may not see. My pediatrist may not see or care that I have sleep apnea, but it becomes relevant when we start planning a procedure that involves twilight sedation (for any sedation, because of sleep apnea an anesthesiologist is required to be present). My sleep issue is not necessarily relevant to my toe pain, nor something that the pediatrist would think to ask about, but it becomes relevant when the doctor is recommending a treatment plan.

And with that, I now have a task on my to do list to create a 5-minute medical history for myself. What type of information do you think it is important, as a patient, to include in a patient generated 5-minute medical history?

8 thoughts on “patient generated 5-minute medical history

  1. Caroline Ronten

    Medical allergies first of all – I’m allergic to penicillins and benadryl as well as codeine and a few other things. Chronic diseases. Anything from the last six months – falls, vaccines, hospitalizations, etc. I could go on….

    Reply
  2. Elissa Malcohn

    I use this Vial of Life form as a template:
    http://www.vialoflife.com/print-free-vial-kits/

    I also maintain a questions/comments file that I print out before my appointment. I start a new one whenever I come up with a question/comment that can wait until my appointment, or whenever anything changes that my doctor should know about. That way, the only thing I need to remember is just to print out the file and take it with me. I can add to the file at any time, even months before an appointment.

    Reply
    1. Becky

      I do this as well. I have list for each of my doctors. But the history is more for when I see a new doctor, or for changes to health information relating to other doctors. Like when something happens at my ophthalmologist that I think my oncologist might be interested in (usually it is the other way around). It is also a great thing to have handy in case I end up in urgent care or emergency, especially while traveling … a short, concise, these are the important things that any health professional needs to know about my current health conditions (and relevant health history).

      Reply
  3. mytriplenegativelife

    I enjoyed your post. It is a great idea to keep track of your history and be your own advocate. Here is a few suggestions that may be included….List of medications. Any allergies at all- to medications, food, surgical tapes or dressings . Do you have Hayfever? List of medical and surgical history. If going for surgery any problems with previous general anaesthetics. Recent reports of blood tests if available. Copies of x rays or scans if relevant.
    That’s all I can think of! Hope it helps.

    Reply
    1. Becky Post author

      Thanks. Yes, it helps … I think there is a lot, it is just a matter of figuring out what is most important.

      Reply
  4. Dina Balatti

    I have created my own called “Medical History – Breast Cancer History, mammograms/ ultrasounds/ biopsies/ surgeries, and Other Major Medical History” in a word Doc: not only for my easy reference to test dates, etc, but for other doctors I may see for the first time.
    It includes (Section titles and Brief Description):
    • BREAST CANCER HISTORY (dx details, dates and details/doctors/locations of all tests, results, surgeries, major appts, etc).,
    • Summary of Biopsies Done since dx
    • Summary of Mammograms/US done since dx
    • Summary of Breast MRIs done since dx
    • Med History OTHER:
    – (migraines, etc, inc all ttmts, tests),
    – ‘other body part’ tests, scans, results, details
    • Preventative Care/ Immunizations
    • Medication List and Med Allergies/Alerts
    • OB/GYN History
    • Bloodwork
    • Family History
    • Contact List of Physician/Hospital/Treatment Center/Labs list

    Reply
    1. Becky Post author

      This is exactly what I was thinking. I may setup a template for people – but the idea is, what can you fit on a quick 2-page primer for any physician you see that might not have knowledge of other medical conditions.

      Reply

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