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Accurate health history is important
POCATELLO — Have you ever wondered why it is always the same 20 questions when you visit your health care provider? This is because each time a person is seen by a medical provider, health history information must be gathered. A health history identifies health care needs and helps health professionals develop a safe and accurate plan of care, establish attainable outcomes, and determine if consultation with a specialist is needed. Though each provider keeps a record of your health history, each will ask those same questions just in case something new may be discovered or remembered. In this article we identify what a health history is and why it is important. We’ll describe how to keep personal health records, where health information can be located, and when you may need the information.
What is a health history? Though not a comprehensive list, a health history includes a person’s: • Blood type.
• Date of last physical examination and any concerns or problems discovered. • Name and number of physician, pharmacist, dentist, and other health care providers.
• Allergies (including those from medications, foods, anesthesia, or products such as latex). • All prescribed and over-the-counter medications including dose, frequency (when and how often they are taken) and purpose.
• Family medical history such as diabetes, heart disease, cancer, stroke or mental impairment. • Emergency contact information.
• Health insurance information. • Dates and results of diagnostic procedures such as laboratory studies, X-rays, ultrasounds.
• Major illnesses and surgeries. • Any chronic problems or concerns.
• Advance directives and living wills. • Record of immunizations, vaccines and titers.
Why is knowing your health history important? Having a record of and knowing your health history will streamline the information sharing process as well as help you know what questions to ask. When the health care professional receives accurate and current information, repetitive tests, questions, procedures, and charges are avoided. According to Emily Newberry, family nurse practitioner, “Treatments are complex and are affected by all aspects of a patient’s health history. A health care professional may need to alter a certain treatment based on a patient’s history.” But that will not be possible without accurate information. Health care professionals see many patients per day, providing limited personal or social time. Patients take charge of their own health by keeping accurate and up-to-date records, knowing about their own health history, and asking needed questions.
How should I record my health history? Some easy, convenient ways to keep a personal record of your health and medical history include: • Keeping a careful, objective record about all major health events. • Using charts, graphs and spreadsheets that document and store health information. • Keeping a list of all medications (prescribed and over-the-counter) and supplements, along with dosages, reason for taking, usual time taken, when started, and last taken. To make keeping records even easier, visit the AARP Web site http://www.aarp.org/health/staying_healthy/prevention/a2004-03-01-healthhistory.html, for templates and charts that you can download from your computer. Where do I find my health history? Health information and family history can be discovered by interviewing relatives and reviewing medical records. If you do not have access to this information due to lost medical records or adoption, there are alternatives to gathering this information. Sources such as obituaries, old family letters, death certificates and birth certificates may help fill in some of the blanks. Family photos may also provide information on obvious physical problems such as obesity, osteoporosis, skin problems, nutritional deficits or growth abnormalities. If you are still unable to discover your health or family history, we encourage you to get regular physical exams, including routine blood work such as cholesterol, sugar and thyroid levels. Also, keep up on recommended diagnostic examinations such as mammograms, colonoscopies and prostate exams. Keeping an accurate health history is a proactive way to ensure the safest, most efficient quality health care. This article was written by Malinda McRea and Jennifer Sanderson, each a current Licensed Practical Nurse and student in the Associate Degree Registered Nurse Program at the College of Technology, Idaho State University. Article RatingReader CommentsSubmit a CommentCommenting RulesWe encourage your feedback and dialog. All comments are subject to deletion by our Web staff.
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