How do you maintain a medical and health record?
Why keep a medical and health record?
Currently the NHS does NOT have a single summary of all aspects of your previous and current health information – maybe one day. Hospital, GP and pharmacy computers do not link up.
It is therefore a good idea to keep a record of all your medical information. As you cannot assume the (perhaps new) health professional in front of you, knows all about you.
What should this information contain?
- A summary of your healthcare over your life. These can be physical or computer notes, or photos on your phone.
- A list of long-term conditions – e.g. operations, hospital letters (e.g. from clinic or a discharge summary after a hospital admission) and allergies
- A print out (or photo on your phone) of the medications you take, given to you by the pharmacy when you collect your medications. If you do not have one, your GP surgery can reprint this list easily for you.
Whenever you attend your GP, hospital (either for a routine appointment or A&E or any other out-of-hours service), you need access to all this information.
What can happens if you do not have a medical record?
Mistakes. Doctors and nurses may make a mistake if they do not know all about you. It is also quicker for a new health professional not to have to ask many questions. This makes more time for them to examine you, and think about the best plan.
Summary
We have described how to keep a medical record and why. It is one of the most important things you can do, to contribute to your healthcare.
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