The Importance of Keeping Your Medical Record Current
Updated January 01, 2014.
Osteoarthritis is among the diseases that have no cure. Symptoms like joint pain and decreased range of motion usually begin gradually, and may eventually lead to decreased mobility.
While it may seem like "it is what it is," there is a lot that can be done to manage osteoarthritis. Yet, patients can fall into a rut and stop discussing their concerns with their doctor. They just go through the motions at a doctor's appointment and barely participate.
They sort of just show up, assuming nothing more can be done.
I had a converation with an elderly osteoarthritis patient recently. I asked if the woman told her doctor about all of her latest health concerns and she replied "No, he knows me. He has taken care of me for years. I don't have to say a word when I go see him." I can't explain the sensation I felt when I heard that. Could the woman be farther off from what she needs to be doing? It's her responsibility, as it is of every patient, to make sure her medical record is current. What do I mean by keeping your medical record current? When you see your doctor, each and every time, you should cover 8 essential points. If you are prepared to discuss what has changed since you last saw the doctor, the conversation will proceed effortlessly. And in the end, your medical record will continue to be current.
Discuss your primary complaint with your doctor. Tell your doctor what is most bothersome -- even if it was discussed during a previous visit, by bringing it up again it lets your doctor know the issue is not resolved.
Discuss any new symptoms you have been experiencing. Discuss when the symptom first appeared and what you were doing that might have brought it on. Have your doctor explain the significance of the newest development. How will it affect you? What can you expect?
Discuss which of your previous complaints have been resolved. Perhaps get a sense of what worked to resolve a particular problem that may work again for your newest symptoms, if possible.
Discuss persistent problems -- problems you discussed before that continue to linger. To reference the aforementioned elderly woman, she felt she needed to bring up a problem once and then the doctor does what he can. But persistent problems must be discussed during each doctor visit. Your medical record must reflect an ongoing issue.
Review what has worked well and what is not working. Go over your treatment regimen each time you see your doctor. Make determinations about what's effective or what should be changed. Be open to new ideas from your doctor. If his idea is not something you want to try now, keep an open mind for a later time.
Review lab and test results which may have come back since your last visit. Have your doctor interpret any pertinent results for you. Your understanding of test results is important and promotes compliance with your treatment plan.
Review medications each time you see your doctor. You may still be taking a medication for a problem that resolved. The review of medications will ascertain that there is a reason for each pill you take.
Summarize the discussion with your doctor to decide if any treatment changes need to be made or if you should stay the course.
Realize that you are not your doctor's only patient. Your doctor must keep track of many patients -- each one with a detailed medical history. If you cover the 8 talking points during each visit, you can feel you've informed your doctor completely and kept your medical record current. It's easy then, for your doctor to refer to your medical record at any time, or for insurance companies to access the record for information they need.
Osteoarthritis is among the diseases that have no cure. Symptoms like joint pain and decreased range of motion usually begin gradually, and may eventually lead to decreased mobility.
While it may seem like "it is what it is," there is a lot that can be done to manage osteoarthritis. Yet, patients can fall into a rut and stop discussing their concerns with their doctor. They just go through the motions at a doctor's appointment and barely participate.
They sort of just show up, assuming nothing more can be done.
I had a converation with an elderly osteoarthritis patient recently. I asked if the woman told her doctor about all of her latest health concerns and she replied "No, he knows me. He has taken care of me for years. I don't have to say a word when I go see him." I can't explain the sensation I felt when I heard that. Could the woman be farther off from what she needs to be doing? It's her responsibility, as it is of every patient, to make sure her medical record is current. What do I mean by keeping your medical record current? When you see your doctor, each and every time, you should cover 8 essential points. If you are prepared to discuss what has changed since you last saw the doctor, the conversation will proceed effortlessly. And in the end, your medical record will continue to be current.
8 Essential Talking Points With Your Doctor
Discuss your primary complaint with your doctor. Tell your doctor what is most bothersome -- even if it was discussed during a previous visit, by bringing it up again it lets your doctor know the issue is not resolved.
Discuss any new symptoms you have been experiencing. Discuss when the symptom first appeared and what you were doing that might have brought it on. Have your doctor explain the significance of the newest development. How will it affect you? What can you expect?
Discuss which of your previous complaints have been resolved. Perhaps get a sense of what worked to resolve a particular problem that may work again for your newest symptoms, if possible.
Discuss persistent problems -- problems you discussed before that continue to linger. To reference the aforementioned elderly woman, she felt she needed to bring up a problem once and then the doctor does what he can. But persistent problems must be discussed during each doctor visit. Your medical record must reflect an ongoing issue.
Review what has worked well and what is not working. Go over your treatment regimen each time you see your doctor. Make determinations about what's effective or what should be changed. Be open to new ideas from your doctor. If his idea is not something you want to try now, keep an open mind for a later time.
Review lab and test results which may have come back since your last visit. Have your doctor interpret any pertinent results for you. Your understanding of test results is important and promotes compliance with your treatment plan.
Review medications each time you see your doctor. You may still be taking a medication for a problem that resolved. The review of medications will ascertain that there is a reason for each pill you take.
Summarize the discussion with your doctor to decide if any treatment changes need to be made or if you should stay the course.
The Bottom Line
Realize that you are not your doctor's only patient. Your doctor must keep track of many patients -- each one with a detailed medical history. If you cover the 8 talking points during each visit, you can feel you've informed your doctor completely and kept your medical record current. It's easy then, for your doctor to refer to your medical record at any time, or for insurance companies to access the record for information they need.
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