Recently the hospital where my partners and I see patients has changed over to an electronic medical record. This has been an expected change and, overall, I am sure will be for the benefit of our patient population. However, like anything that requires change, there are a few hiccups to be worked out. In transitioning to the new system a completely new medical record is being created. While the old records are available for access and use, they are not part of the new electronic medical records until the specific information is entered as past medical history. This specific hiccup brings up a particular point for families.
Most families realize it is important to remember a medication or food allergy in keeping track of their own or their child’s health. But oftentimes other medical history is not logged away as carefully. In reality when a child visits his doctor, has a medical procedure or experiences an emergency room visit, a medical history will be taken. This history should include any hospitalizations, chronic medical problems, broken bones, behavioral or developmental abnormalities that a child has been diagnosed with. In addition, the care provider should be aware of any prior surgeries or procedures that have been performed on this child. These may include x-rays or MRI studies. This information helps to assure that nothing will be missed in taking care of a patient. This would include anything from continuing a home medication to not repeating a procedure that has already been completed.
Family life is busy. And many of these details become seemingly irrelevant as soon as the particular incident has resolved itself. However, these details can be important over the course of years when new or different problems arise. For these reasons it is important for families to maintain a good health record. This should be an easily accessible single sheet of paper that contains a succinct list of important medical information. Thankfully, for most children this paper will usually be almost blank! This sheet will come in handy should others be caring for the child and need to seek medical attention. The information is justifiably important if a child is traveling unaccompanied, or simply to have on hand for the regular hectic family.
Here is an example of the type of information that should be continually updated for each member of the family:
EMERGENCY CONTACTS with PHONE NUMBERS
PAST MEDICAL HISTORY:
HOSPITALIZATIONS with diagnosis and dates
PROCEDURES with reason completed/findings and dates
SURGERIES with reason completed/findings and dates
STUDIES (i.e. X-ray, CT, MRI, ULTRASOUND) with reason completed and dates.
MEDICATIONS (include supplements)
SPECIALISTS with names and contact numbers.
This brief list of medical information will keep your family informed and prepared for any occasion that may arise!