Write it down: Document your medical history

Write it down: Document your medical history.

While documentation is the first thing nurses are taught, do you realize how important it is for you to document every encounter you have with a healthcare professional? More often than not, we have multiple medical providers. Can you recall your last visit with one of them and what was discussed or prescribed? Can you relay that information to another physician? Can you recall the date of your last bloodwork, EKG, or colonoscopy?  

 

Maintaining a brief record of medical encounters can be as easy as keeping a small notebook in your purse or pocket. For a long-term illness or a hospitalization, you may wish to keep a specific journal, notebook or binder with details pertaining to that issue. You can organize medical records and receipts as well as record thoughts and questions you may have about a specific medical issue.  

 

In the Pastoral Care Office, we have examples of small notebooks as described above, as well as a hospital journal you can use when admitted to the hospital. Both are useful tools to keep track of your medical history. Stop by anytime and pick one up. You can also use this sample notebook to get an idea of how to make your own. There are also smartphone apps to help document your medical history. You can then share the information on your phone with any physician’s office.  

 

No matter how you do it, keep up with your medical history documentation to assure the best medical care possible. 

Linda M. Walsh, RN, BSN 

lwalshrn@st-ann.org

770-552-6400 x6019 

Photo by lilartsy on Unsplash