A Guide to Your Medical History

We’ve all been at the doctor’s office when the questions arise. They come up like a flood, in rapid fire, and are immediately disorienting. Please share your medical history. Oh, you had this test? With whom, and what were the results, please go by date? Don’t have exact details? That’s fine, we’ll simply have to do without the important information.

Yes, your medical history matters—but meeting a new provider doesn’t need to be so stressful. An ounce of preparation is worth a pound of cure. Patient advocates on Solace help take the mysteries out of your medical history and take on the time-consuming process of digging up and verifying your health information, securely. Whether you’re searching for a new primary care provider or a specialist, it’s important for you as an individual to understand how your medical history is critical to your future health.

Looking to put together a comprehensive medical record yourself? Here are a few things to know:

Key items to prepare:

1. Chronic health issues

‍This includes anything for which you’ve been medically evaluated by a doctor, or any issue that’s being considered on an ongoing basis. You’ll want to include as much as you can about your illness, including the timing of when it started, any ongoing concerns, relative improvement or deterioration in symptoms, and changes in the overall issue presentation. If you have past health problems that were at one time chronic but no longer are, it’s important to include those as well.

2. Medications

‍Make a thorough list of all your medications, past and present. It’s important to be as deliberate as possible on this. Start with medications you’re currently taking, and also share any medications that you’re allergic to, had a bad reaction to, or that simply didn’t work. You should also list any medications that you’ve been prescribed in the past, even if they were simple and worked. A detailed medication history helps your provider know which options may work best for you going forward.

3. Lab results

‍These are generally urine and blood tests, full or partial panels. They don’t have to be particularly recent, either; any lab tests you’ve had within the last few years will be helpful. Make sure to bring any repeat or flagged results. Looking at your lab results over time will help paint a better picture than any one test in isolation.

4. Radiology and imaging

‍Similar to lab results, you’ll want to bring any radiology or imaging you’ve ever had performed. The date range is less relevant here, so you should consider going back a decade or more and bring anything you have—, even if your result ended up being considered completely clean.

5. Other medical diagnostics

‍This could include biopsies, EKG results, and any report that doesn’t fit neatly into labs or imaging. If you have reports related to the diagnosis or management of a current condition, those will be particularly useful to your new physician.

6. Hospital and emergency department reports 

Each time you’ve visited the emergency room or been hospitalized for any reason, a report has been written by your health providers, for your future health providers. You’ll want to track down copies of each of these. Important to note, these department records are not the same reports as the patient discharge instructions that are handed out.

Tip: As a patient, you have the right to obtain your own records. You may have to file a HIPAA medical records written request to obtain certain medical records. However, some clinicians may just print them out in the office for you.

7. List of involved clinicians

List each doctor and healthcare provider who has previously been involved with your care or with the care of your loved one. Often, your current doctor may know your past team and may backchannel information if they are unclear about something specific in your medical history. Sharing the reason why each doctor was seen can be immensely helpful to your clinician.

For each specialist, it’s useful to list the dates of when you established care and note how often you saw each provider. 

8. Clinical visit notes

All visit notes written by your primary care doctor and any medical specialists you’ve seen can be useful as you document your medical history for future care. Try and get as many notes as you can. HIPAA gives patients and their legally designated surrogates the right to obtain their medical records upon request. If you run into challenges on this front, reach out to an advocate on Solace for help.

9. Advance care planning documents

These include any advance directives, living wills, pre-hospital DNRs, or POLST forms. These are incredibly valuable to have on record with your physician, but moreover, these give you the power to provide critical input and guidance on how your doctor should  recommend or proceed with certain treatments.

How to share with your doctor

That’s quite a list. Once you’ve compiled your medical history, it’s important to bring multiple copies with you to your first office visit. When you come to your appointment, share one copy with the front desk during check-in. Given the time-per-patient limitations many doctors face, your team may not get a chance to visit your history ahead of time, but they’ll keep your history on file.

During your appointment, give your doctor a second copy and make sure to review it with them. Ask them to take a look, and make sure to clarify any items that are confusing or cumbersome. The goal of owning your medical history is to  facilitate a solid information transfer and allow your doctor to understand your full history, so they can provide the best possible care based upon the most accurate information.

And if this sounds like a lot? Don’t worry, you’re not alone. Reach out to a patient advocate on Solace today, and you’ll find a medical expert who will be happy to help you put it all together.