Thursday, October 18, 2007

Organizing Your Personal Medical Files

Although this topic does not really affect directly how a patient deals with the medical community, I thought that it might be of benefit to share how I maintain my personal medical files.

I have two main conditions that affect my daily abilities. For better understanding, these conditions are severe enough that each are considered a disabling condition. Additionally, I have a few minor conditions that while not disabling, are surely affected by the two major conditions. For example:

Parkinsonism – major condition causing disability
Degenerative Joint Disease of the Spine – major condition causing disability
Osteoarthritis (knees) – minor condition not causing disability
Bursitis (hip) – minor condition not causing disability
Restless Leg Syndrome – minor condition not causing disability

Each patient’s medical condition(s) is / are unique to him / her. One patient may be dealing with one major chronic condition only, while another patient may have more than one major chronic condition. If a patient has additional minor conditions thrown into the mix, the variables are endless.

Based on my conditions above, I created a filing system for the sole purpose of quick and easy accessibility. Because I am dealing with more than one condition, I have a large quantity of records. While all of these records are important, not all of these records need to be provided to each physician. Therefore, due to the number of conditions I have been diagnosed with, plus the large volume of records associated with these conditions, I came up with the following file system:

File #1 – Complete set of all medical records in my possession

File #2 – Complete set of all medical records relative to Parkinsonism; includes any reports from specialist during the diagnosis process, diagnostic tests done to rule out other disorders, a copy of any related written documentation, and copy of personal medical journal entries that relate to Parkinsonism.

File #3 – Complete set of all medical records relative to Degenerative Joint Disease of the Spine; includes any reports from specialist during the diagnosis process, surgical reports, diagnostic tests, a copy of any related written documentation, and copy of personal medical journal entries that relate to the spine.

File #4 – Complete set of all diagnostic tests, regardless of type or conditions associated with these tests

File #5 – Complete set of all types of written documentation; includes written correspondence and personal medical journal.

Here is how this filing system assists me with quick and easy access to specific records. I will refer to the file number followed by a brief explanation for the purpose of that file.

File #1 – If I were to find myself in the position of having to see a new Primary Care Physician, that physician will need to have a complete set of my records. Although the physician’s office personnel would likely send out for copies of my records, the ability to offer the majority of my records during an initial appointment could give the physician a jumpstart on becoming familiar with my health related issues. Additionally, during an initial diagnosis process for an unidentified condition, a specialist should be provided a complete set of records, especially any results from diagnostic tests. This complete history, in addition to the exam, will assist the specialist who is attempting to determine a potential diagnosis and the course of action necessary to reach a diagnosis.

File #2 – Once a confirmed diagnosis of Parkinsonism was given, any specialist who I see now or will see in the future, only needs those records that are specific for Parkinsonism, unless otherwise requested. I have found that verbal information given to a specialist about other unrelated conditions is usually sufficient.

File #3 – Once a confirmed diagnosis of Degenerative Disc Disease of the Spine was given, any specialist I see in the future will only need those records that are specific to my history with this condition. This includes all documents related to diagnostic testing, and in my case, two surgeries. Again, I have found that verbally communicating the other unrelated conditions to a specialist is usually sufficient.

File #4 – Although this file comes in handy primarily when dealing with a new “unknown” potential chronic condition, I continue to keep this file for my own easy reference. For example, I will occasionally think about something I want to research about my conditions, and many times will pull my diagnostic test results for the correct medical terminologies or because it pertains specifically to the actual information on a specific diagnostic report that I want to research.

File #5 – This file gives a running history in writing and from my perspective, about every aspect of my health. It includes chronological information that can be used to gauge progression as well as the length of time that each condition has existed in my life. This information is invaluable not only when dealing with the medical community, but also when dealing with Social Security.

Essentially, I created my files based on my own experiences, which included the many specialists I have seen and what type of information each specialist required. Additionally, the documents in each file are arranged in chronological order by date, with the most recently dated document in front. I found that this not only assists me, but also assists a specialist who can look at my medical records from the beginning to the present, in chronological order. Again, each patient’s medical history is different. In my case, my system helps me spend less time figuring out what to give to a particular specialist, since I have created condition specific files. I only need to grab the file, make a copy, and proceed to the appointment. I do not have to spend hours digging through all of my records trying to determine which ones to provide to a specialist. Finally, I do not end up providing information overload to a specialist; by including information that is not relevent to the condition that specialist treats.

I have found that organization has become a key benefit for me, and it is just another aspect of dealing with my chronic conditions. It saves me time, which allows me to focus on the more important things in life.

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