Keep A Personal Health Record

Posted on September 2, 2010 by bob in Health

Health literacy has been defined by the World Health Organization (WHO), the U. S. Institute of Medicine (IOM) and the American Medical Association (AMA).  Essentially, this term refers to the degree of a person’s ability to obtain, process, and understand information about health and services necessary for making health related decisions. Researchers, clinicians, and health policy makers have determined that the degree of health literacy is a stronger predictor of health outcomes than factors such as social, financial or educational background, age, or gender, and have linked inadequate health literacy to poorer health outcomes regardless of the illness.

Information about health issues is often obtained from friends, family, internet sites, or advertisements.  However, the accuracy of this information as it applies to your particular concern is difficult to determine, and may be difficult to understand. Obtaining information about your health concerns from your health provider may be complicated by having multiple health care providers for different concerns or chronic illnesses and not being sure which concern should be discussed with which provider. Obtaining information from your health care provider may be also be a challenge due to limited time for office visits, stress of the visit, distractions while you are being given information, or not understanding printed materials that are provided.

Some strategies you can consider to increase your literacy regarding your own health concerns include:

1) Maintaining your own personal health record. This can be in the form of a separate spiral bound notebook or file on your computer for each individual in your family.  This should include:
a. Dates of visits to health care provider, name of the provider seen, and the reason of the visit.
b. Any diagnostic tests (lab, x-ray, etc.) that are done, with results entered when obtained
c. Any prescriptions with name, dose, time and frequency to take, reason for the medication,  duration of the medication’s action, how long you should take the medication,  any possible side effects, and for what symptoms you should notify your provider
d. Names of any referrals for other treatment, a date by when they should be completed and specific instructions for follow-up visits with the primary health care provider or the provider to whom you were referred
e. Copies of any health information pamphlets

Questions that arise can be recorded in this notebook between visits.  Your personal record can be taken to each health care provider for reference in asking your questions and clarifying instructions among various providers.

2) Requesting information in “plain language” or for directions to be written during the visit into your personal health record by you or your health care provider for referral after you leave the health care facility.

3) Requesting your provider to allow you to “teach back” the information that has been provided to you.  In this method, you repeat back to your provider what you believe you have just heard, which allows further discussion of any area in which you are uncertain about the message.

Coping with health concerns requires active involvement, awareness of health changes, and participation in decisions regarding your health or the health of one for whom you care.

Arlene Morris

Arlene H. Morris, RN, Ed.D. is a Distinguished Teaching Associate Professor in the Auburn Montgomery School of Nursing, where she enjoys teaching content regarding gerontology and professional nursing issues.