So you've decided to start a personal health record (PHR) and you're not sure where to start. Most of it will rely on a sharpness of your own memory and a fax from your doctor. The first 5 of the 10 things to put in your PHR will be from your own memory, talking to your doctor and family members. The last 5 are actual records you will need to get from your doctor's office and any hospital where you have been treated.
1. Contact Info
Think of a PHR as your health resume. Your contact information is always at the top of the page or the beginning. The first of the 10 things to put in your PHR will be your name, your address and your telephone numbers. You'll also want to add your emergency contact info. Their name and phone numbers as well as their relation to you. It is also important to have your doctor's info on hand in the contacts section. That way you won't have to search through the phone book or dig for their business card in your wallet. Last, you'll want to add your insurance information: the company name, type of plan, group number and policy ID. Your insurance policy number isn't something you recite on a daily basis, like a phone or credit card number, so it's good to have it on hand in your record. If you have certain religious beliefs, you may want to describe them as well, such as whether or not you would accept organ or blood donations.
2. Family History
The family history section of your PHR will include all people whom you are genetically related to you. That would include parents, grandparents and great grandparents, siblings and half siblings, aunts and uncles, nieces and nephews and your own children. Keeping a record of your family's health history is a good way of keeping track of your own health. Conditions such as Alzehimer's, asthma, diabetes and mental illnesses tend to run in families have have a good possibility of effecting you if one or more of your family members has a certain condition. Even if your relatives have already passed away, it's still important to add their information and the cause of their death. Family history is something that will need to be continually updated, as your relatives' conditions may change over time.
Making a list of the medications you take, past and present, is very important to put in your PHR. You'll want to include prescription medications as well as over the counter ones, such as vitamins and supplements. The information you'll want to log will be the medication name, the dosage and the frequency. Make sure you keep your medication list up to date as well, as your doctor may switch your meds on a frequent basis or the names may change. It's also very important to list any allergies you have to certain medications and what reaction you had.
Along with allergies to medications, you'll list your other allergies as well in your PHR. You may want to categorize them by severity: mild (rash and/or congestion), moderate (difficulty breathing) and severe (anaphylaxis). Or categorize them by allergen, such as environmental, medication, venom (from insects) and medication. If you have received treatment in the past or present, such as shots, oral medication or homeopathy, be sure to describe them and if they were successful or not.
5. Your Medical Conditions
Now, let's focus on just your medical conditions. You'll want to list both past and present. Past would be illnesses that have already been treated or don't greatly effect you today. Did you have the chickenpox as a child? What about mononucleosis? Were you at one time diagnosed with cancer, treated and are now cancer-free? Current conditions would be illnesses that effect you today. Do you have high cholesterol? Osteoporosis? Are you currently being treated for cancer? Also, with the conditions, list the treatments you have received for them.
6. Progress Notes
Now we get to the part that may require a scanner or downloading PDF files. Many people find that filing records chronologically, with the most recent on top, to be a most convenient. Progress notes, or follow up notes, are made by your doctor when you see him/her for consultations and to discuss previous procedures and labs.
7. Lab Results
Your lab results will mainly be from any blood draw that you have done. Labs may also include results from urine and tissue samples. You will also be able to better keep track of the frequency of your routine labs, such as lipid panels, and make sure they get done on time.
8. Diagnostic Scans and X Rays
Diagnostic scans would be considered CTs, MRIs, ultrasounds, mammograms, bone density scans and PET scans. Procedures like colonoscopies and heart catheterizations can also go in diagnostic scans as well. X Rays will could be the actual X Ray or the written findings report from the doctor.
Hospitalization records include both emergency room visits as well as inpatient treatment.
Surgery reports will tell you the history that led up to the procedure and a detailed description of what was performed. You may also want to put pathology reports from biopsies in surgeries as well.