The Information Most Important to Include on Your Medical Record


We have all had the experience of sitting in the waiting room of a doctor’s office with a clipboard or tablet loaded with forms ready to be filled out. You may wonder why as you have already filled out similar forms at your other healthcare providers, and maybe even at this office.

Experts say it is good to remember there are several reasons why you are being asked for your medical history again. To start with, your health may have changed. Additionally not all doctor offices have access to the same digital information; or it may not have been updated. Another thing is a specialist may be looking for different information not typically collected by your primary care physician. Remember your refusal to answer questions could make it harder for your doctor to see the full picture of your problem; or at the very least make you look uncooperative. Dr. Robert Shmerling, a rheumatologist and senior faculty editor at Harvard Health Publishing, agrees you are not obligated to fill out your medical history but says the response from the practice might be, 'How can we provide the best care if you don't provide the information?”

So what is the most important information to include? The Harvard Health Publishing article highlights the most useful things to make sure your healthcare provider knows. This includes letting them know about:
  • chronic or new symptoms and conditions
  • past surgeries
  • family medical history
  • insurance information
  • current prescription and over-the counter medicines, supplements, vitamins, and any herbal remedies or complementary medicines you use
  • medication allergies
  • vaccination history
  • any screening tests you've had, so they won't be prescribed unnecessarily
  • any metal implants you have, which could affect screenings.
If you are worried about giving out so much personal information, remember the Health Insurance Portability and Accountability Act (HIPAA), a federal law, protects your health information with very strict rules about who can access it and how it can be shared.

At MorningStar of Littleton, we provide senior living that allows residents to safely and comfortably age in place. Our community has 65 stylish private assisted living suites in a choice of studio and one-and-two-bedrooms. MorningStar proudly offers holistic Alzheimers care Littleton, CO families can trust to meet their loved one’s every need. Please contact us for availability and ask about our Move-in Specials. Join us for a presentation on “Understanding Dementia” on Wednesday, August 14, 3:30–4:30pm. 

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