1) Diagnoses/PMH/Medications always available in med chart 2) Presenting symptoms
When accompanying friends and family to hospital, I would say that always there is an intake where the patient is to recount the diagnoses, medications and past history over and over again. When one is sick or is accompanied by someone who is not aware of everything, many important parts of the history can be missed and/or not recorded.
This is dangerous and can be easily rectified by the electronic medical record. The patient’s total sum of diagnoses, medications (listed by date of prescription), and past history by date need to be available to the health care personnel immediately, to draw upon for additional insight and information on the patient.
It seems when someone even returns to the same facility, these past diagnoses are not listed in the most available medical chart and can be overlooked unless the health practitioner takes the “time” to research this and go back through the record.
I have known of very important information being unaware of, and the patient was supposed to be the provider of this. That is the wrong emphasis on patient responsibility (especially when one is sick). The institution should have all this information readily available.
Also often doctors think someone is med-seeking when they have a serious diagnosis from the past that is overlooked. That is a built-in injustice to patients who truly need help. I wish this prejudice would be more closely looked into. Pain as a presenting symptom for cancer is overlooked!!! I am thinking of a dear friend with stage 4 cancer.
Comment By: June Fowler
Date & Time: March 24, 2010 at 5:03 pm
BJC offers a free online personal health record called myHealthFolders that allows patients to input their health information at their convenience and retrieve it when it is needed. You can get more information about this tool, by clicking on the link at the bottom of this site.