October 2002

Keeping an accurate health history

When you go to a new doctor, the first thing he/she will ask about is your health history. On return visits, he/she will update your history. Having an accurate record of your illnesses, injuries, treatments, current conditions, and family history is critical to obtain good health care. However, when you give this information to the doctor, sometimes you may forget something. And sometimes the doctor might miss some important things you say.

Laura's 7-year-old daughter started having seizures several times a week during her sleep. She was referred to a neurologist for a complete evaluation. Laura had kept a record of the seizures and had even videotaped several of them. She had documented how often they occurred, the times of night they occurred, and what they looked like. Her daughter started treatment with an antiepileptic drug.

A few weeks later, she received a copy of her daughter's medical record from the neurologist. She was shocked to see that some important parts of her daughter's medical history were missing from the record, and that other parts were completely incorrect. She was concerned that her daughter's treatment was based on inaccurate and incomplete medical information. Laura sent the neurologist a copy of her written record of her daughter's seizure history and requested that the history be corrected and Laura's summary added to her medical file.

Laura might have avoided this problem if she had given the doctor a copy of the health history at the initial visit. Even though she recited the history from her record, the doctor did not write down correctly what she said. For example, an accurate description of seizures is necessary to identify the type of seizure and determine which drug is the most likely to control them. As it turned out, the doctor and Laura tried three different drugs (at varying dosages) over one year before they found one that worked.

You can help ensure the doctor gets an accurate health history by keeping a record of your information and updating the record if anything changes. We have created a form you can use to record your health history. Start now so you are ready for your next visit to the health care provider, emergency room, a specialist, or the hospital.

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