This article lists the critical medical information that doctors use as part of medical decision making. Having the latest info on hand makes for rapid diagnosis and treatment.
Basic Medical Information
1. Name Date of Birth Address Insurance Social Security
2. Height and weight with the units. (For medication dosing and imaging with weight limits).
3. Past Medical history: Includes all diseases previously and currently being treated for from head to toe.
Some information related to the other organ systems that may not seem to be connected to your presenting complaint is also essential. For example, previous kidney failures are relevant to a heart condition if you will need to have an angiogram. If that information is missing, then there is a risk of further kidney damage that may lead to dialysis.
Medical terms may be quite long to fill up on a sheet of paper so you can write medically acceptable abbreviations like MI, CVA, COPD. You can look at this website for standard medical abbreviations. Do NOT invent your own no matter how obvious it is to you because it can mean something else.
4. Allergies: X-ray dye, food, and medications, and what are the reactions? Hives, can’ breath, throat closing, or sick to the stomach? Sometimes you may think that it is an allergic reaction, but it may not be. Nausea is an example. You do not want the medication choices to be unnecessarily limited.
5. Past surgical history: Any bodily organs removed. Common are the appendix (appendectomy), gallbladder (cholecystectomy), and uterus (hysterectomy). This part may skip the medical terminologies as long as you say what organ was removed or transplanted. This section also includes stents and grafts to any part of the body and implanted medical devices like pacemakers and AICD in case you need an MRI. Implanted devices can get infected and be a source of fever.
6. Current Medications: This one is critical. The generic name of the medication, how often a day, dose with the right decimal numbers. Example: Digoxin 0.25 mg once a day. Notice the zero before the decimal point. The information can be in a tabulated form to make it easy to read. Describing a pill as “It is the round white one.” does not cut it. There are just too many white pills out there.
7. Social history: Did you ever smoked? How many packs and how many years? When did you quit?
8. Alcohol: How often and how much. It gives the doctors an idea if there may be a liver condition that can be affected by medications. It also alerts the staff about the possibility of alcohol withdrawal, which needs specific treatment.
9. Illicit Drug Use: Cocaine?, Heroin? Other street drugs? Also, state if you are a reformed heroin addict or former alcoholic. This is important because unwanted exposure to opiates may lead to an addiction relapse. There are infections found associated with intravenous drug abusers like hepatitis B and C.
10. Family History: Any history of heart attacks and strokes in your parents and siblings? At what age? Also, note if there is a genetic disease condition that strongly runs in the family
11. Physicians that you are seeing and have seen before. Primary Care physicians, all specialists, surgeons, especially the ones who did the surgery. Sometimes you see them, but no procedures are recommended, or they are just monitoring something like a vascular surgeon that you saw for that Abdominal Aortic aneurysm or your PVD (Peripheral Vascular Disease. It is good to have their telephone numbers with area codes in the vent that you are far away. They can be a source of critical information.
12. Obstetric History: For all females with monthly periods. How many times you have been pregnant and the outcome. Full-term, Premature, Abortion, and living child or children. Previous ectopic pregnancy.
13. The pharmacy where you get all your medications, including the address, telephone numbers, and zip code.
14. Advanced Directives like the Health Care Proxy, Power of Attorney, Do Not Resuscitate (DNR) and the MOLST form (Medical Orders for Life-Sustaining Treatment) should all be signed by the right people.
15. Contact people and telephone numbers at their work, home, or mobile. Especially the Health Care Proxy or HCP and secondary contacts in case the primary HCP is not accessible.
Sounds a lot, right? You are probably thinking about the answers to those questions in your mind as you were reading this article. Now try to imagine answering all of those questions when you are in severe pain, having shortness of breath, bleeding, or drowsy.
The Complete Series of “How to Prepare for that Unplanned Emergency Room Visit”
- Part 1 talks about why preparation is needed for an emergency room visit
- Part 2 lists the most essential medical information to bring to the emergency room.
- Part 3 describes the other medical information that are also important.
- Part 4 enumerates the different ways to carry medical information
- Part 5 lists all the needed medical information in a shortlist that can be copied and pasted to a word processing app ready to be filled.
- Disease Prevention Has a Deadline
- The Two Minute Warning
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Impressive list! Definitely important for the patient to know! Actually this does not just apply to the ER setting but in any patient and doctor encounter, the above information is very much helpful! It makes treating patients easier for doctors.
I would like to suggest that a female patient should also know the first day of her last menstrual period and to inform the ER doctor if there is a possibility she is pregnant. It does not have to necessarily go into the list because that means frequent updating