lDON'T FORGET!
Personal Healthcare Record
ISBN 978-0-9744643-3-6
ISBN 978-0-9744643-4-3
Copyright, Tortuga Publishing, 2011
A division of
Tortuga Enterprises LLC
All rights reserved worldwide
Tortuga Enterprises LLC
1142 S. Diamond Bar Blvd. #261
Diamond Bar, CA 91765
www.CharlaSpence.com
Contact Us: charlaspence@verizon.net
Facts & Questions (FAQs)
Facts & Questions (FAQs) A5 - Ideally, the PHR should begin at birth and be continually Remember! – To keep information current, you must continue to The PHR was developed to be used in a couple of formats; either as Table of Contents Both PHRs have 3 main sections (128 pages) The age appropriate A. Journal Pages Note or staple any new information from office visits and other B. Medical History Work with your healthcare professionals and existing records to Medical History ‘At A Glance’ For Emergency Personnel Personal Information Emergency Contact Durable Power of Attorney for Healthcare/Advanced Directive Medications Common Health Conditions Early Childhood – Birth Info, Shot Record Hearing Records (optional cross reference – see Journal pages) Vision Records (optional cross reference – see Journal pages) C. Health Reference Information Review the health reference section that answers questions about - Templates for photocopying if you need additional pages in - Frequently Asked Questions (FAQs) and additional hints on Important Healthcare Event Reminders and Checklist Vital Signs Growth Chart – Girls Immunization Schedules Other excellent medical information resources The Author’s Story Frequently Asked Questions (FAQs) Wallet card (Note: Print back to back) Authorization to Treat (Child) (Note: Print back to back) Insurance Verification Form Note: The two blank tabs are provided for individual needs.) The contents of the Personal Healthcare Record are not 5 Simple Steps
Follow these 5 simple steps in completing and maintaining v Prepare a Journal page for: If you do not have a healthcare appointment scheduled, x Punch and insert copies of reports and test results
This sections includes the following information. Please scroll down
to the topic of interest:
For a great audio overview listen to the November 2, 2010
interview on CHW Radio -
http://blogtalkradio.com/cyberhoodwatch Topic: Keeping Your
Personal Healthcare Records Safe with Charla Spence
Q1 - Why is there a need for a PHR?
Q2 - Who was the PHR designed for?
Q3 - Why isn't the PHR in an electronic format?
Q4 - Isn't this information available from my doctor?
Q5 - When should the use of the PHR begin?
Q6 - How do you use a PHR?
Also included:
Table of Contents (for the PHR)
5 Simple Steps (for using Your PHR)
Development Background for the
Personal Healthcare Record (PHR)
Q1 - Why is there a need for a PHR?
A1 - Here are some interesting statistics: According to a GFK
Roper study, the average American patient has 18.7 doctors
during their lifetime (28.4 if over the age of 65) and generated 13
pages of documentation per doctor's visit equaling at least 200
pages in 19 locations. In addition, according to the Journal of
the American Medical Association, 13.6% of doctor's visits were
missing test results and other documents. 44% of the patients
were adversely affected and 59.9% received delayed care or
duplicative services adding cost to the system.
Each stage of our life has a special healthcare focus. Parents are
concerned about the children and adults are concerned
about keeping themselves and or their aging parents healthy.
Because of these different healthcare stages and concerns, there
are two age specific versions of the PHR available:
- Birth to 17 Years Old
- Adult
Birth to 17 Years
- Keep track of all the vital information for your newborn until they
start school.
- The school years are a time of continued development and
exposure to a larger more diverse group of people exposing your
child to other potential healthcare risks making prompt
attention to preventative healthcare routines even more
important. This is a critical period of immunizations,
vaccinations, documenting early development activities.
You will find it easier to keep track of this important
information in this fun and easy to use PHR.
- The adolesencent years often involve more intense
sporting activities not to mention the coming of age for
young women and young men and the healthcare issues
and education at this time in their lives.
Adult (18+) Version
The transition from parental healthcare to assuming the
responsibility for your own healthcare is made easier when
you can just continue tracking your healthcare history based
on the foundation established by your parents in the the
child's version. If this foundation is missing, the PHR
will provide a framework for your to collect the important
relevant information from your childhood. As an adult you
will have new preventative healthcare events like
monitoring health indicators.
In addition, there are 77 million baby boomers entering
their "golden" years and an increasing need for caregivers.
Example: there is an estimated 250,000 Alzheimer's
caregivers today. Predictions are that 1 in 8 men (1 in 6
women - they live longer) will be diagnosed with Alzheimer's
in their lifetime.
That equates to 1/2 million/year by 2010 and 1 million/yr by
2050. And, that is just one healthcare issue. Add to that all
the other medical issues...cancers, diabetes, heart
problems...yikes!
Q2 - Who was the PHR designed for?
A2 - While the caretakers for small children, elderly, chronically
or critically ill might benefit the most from the PHR, all individuals
should maintain and up to date medical record in the case
of undetected medical problems or accidents. At least one other
trusted person should know where your PHR is kept in case
of emergency.
Q3 - Why isn't the PHR in an electronic format?
A3 - There are electronic resources/products on the market.
However, electronic formats are not for everyone. The primary
users of PHRs, the baby boomers, older generation, children,
are not necessarily comfortable or may be incapable of using
computers. Caregivers may find it inconvenient or create
unnecessary steps to maintain records electronically. There
are advantages to having a hard copy record for the younger, tech
savvy generation too. This is one area where low technology
is the best technology’. The health care industry systems are
still not integrated (and may never be due to HIPAA). There
are different systems and different software which require the
user, if interested, to use yet another system to electronically
update their personal health care records. The PHR approach
acknowledges this reality and provides something that the user
can buy, ‘ready to go’, and record with a good old fashion pen or
pencil. They write down the information ‘on the spot’ at their health
care appointment, hole punch any health care documents they
receive and call it good. No extra and unnecessary steps that
many will not take the time to do after the fact.
Another big plus for a non-electronic format is Emergency
Preparedness. In case of a natural disaster, computers may not
work or even be destroyed. Grab you PHR as you are leaving your
home and have everything you need regarding your personal
healthcare.
Facts & figures illuminating the electronic healthcare record challenge.
Healthcare sources, IT Professionals and Privacy Organizations agree that, and referenced here, we are a long way from the ability to have a viable integrated healthcare record system. So what do we do while we wait and continue to age or have medical issues.
Q4 - Isn't this information available from my doctor?Unlike non-living systems that can take their time or be put on the shelf, we are a living system and will continue to encounter healthcare issues at all ages, especially as children and older adults. So, how do we take charge of our health until the electronic world can catch up and provide even a good system?
While keeping a paper based Personal Healthcare Record for yourself and others may only be a bridge system until a fully integrated, reliable, confidential system can be developed, it is essential that you get involved with your own healthcare and the healthcare of those you may be responsible for (children, elderly, critically or chronically ill).
The following is a summary of two of the many articles written on why a useful electronic records are still a long way off.In “Qualms Arise Over Outsourcing of Electronic Medical Records” from the November 1, 2010 Wall Street Journal Article, Health Industry section, here are some key points:
- There is “sensitivity over outsourcing and resistance by American hospitals” to send medical information overseas,
- While the US government has begun handing out nearly 50 billion dollars over the next two years to the information market and “to healthcare providers who adopt electronic medical records, doctors also face a federal mandate to upgrade software as the U.S. switches to a new system of insurance billing codes”.
- Unlike many other industries, “hospitals say they have practical reasons for being reluctant to work with off-shore vendors, citing the efficiency of doing work on site and the potential legal complications of shipping sensitive health information to other countries.” Of course, US tech vendors are competing for this business too; however, they will still need to overcome the huge issues of different systems requirements by hospitals and private physician practices in order to show “meaningful use” of electronic records “or risk losing federal reimbursement for medical care.
- There is movement toward a electronic solution in some areas, usually large healthcare providers like Kaiser Permanente. However, “only about 20% of
- Confidentiality is a major concern. “Some healthcare providers are reluctant to send some patient information overseas…As soon as it leave the confines of the U.S., it’s not subject to the same rigorous laws as we are” India, however, says that “they adhere to the same level of information security as their U.S. counterparts”.
- Besides confidentiality, there are other hesitations in hiring off site or offshore companies. “Designing and installing new medical systems is hard to do off site, let alone offshore.” According to Darren Dworkin, CIO of Cedars-Sinai Medical Center in
In the IT Professionals Featured Article titled Personal Health Records Program Highlight Privacy Issues (Nov. 1, 2010, www.tmcnet.com), A Roundtable discussing the privacy and security requirements for personal health record (PHR) vendors will inform the congressionally mandated report of The Office of National Coordinator for Health Information Technology (ONC). “Four panels will address the current state and evolving nature of PHRs and related technologies (including mobile technologies and social networking), consumer and industry expectations and attitudes toward privacy and security practices, and the pros and cons of different approaches to requirements that should apply to non-Covered Entities[HIPAA] PHRs and related technologies.” Just reading these objectives creates the question, when will these studies ever be finished much less a system implemented that will provide “meaningful” and complete information for our use. Another bureaucratic nightmare!
In summary, the reason why it is important to maintain your own Personal Healthcare Record is that, even with the eventual development of an electronic healthcare system, we are a long way from having a viable all inclusive secure system tailored to each unique patient and healthcare provider’s needs. This can impact your healthcare and the healthcare of the ones you love significantly unless you take charge of your own healthcare needs.
A4 - Yes. But, in addition to the issues in Q3 regarding
healthcare system incompatibility and privacy laws, most of us
see more than one doctor (referrals). In order for the doctor to
treat you properly, he/she must know what has again request your
health history, inquire about what has already been done and so
on. This can become confusing especially when dealing with
multiple doctors or assisting with more than just your own
personal medical concerns.
Q5 - When should the use of the PHR begin?
updated throughout your entire life. Many healthcare
professionals and agencies encourage individuals to "take
charge" of their health by encouraging each individual to follow all
the standard guidelines for diet, exercise, prevention
and maintenance of personal health. The PHR is a perfect place
to track this type of information.
Having an accurate and complete PHR is important for everyone;
however, not everyone has realized the value or taken the time to
develop a personal health care record. Some may even think that
they don’t need one because they are healthy and active; however,
it can be dangerous to assume that, just because you don’t have
any known health concerns now, you don’t have something that has
gone undetected; or, a new condition won’t arise. Think about the
children and athletes who make the news because they died
unexpectedly usually from an undetected medical condition. While
developing a PHR should not be born out of the fear of some major
medical problem, it is important to have accurate and complete
information about your health to assist with prevention and possible
early detection of health problems. Your PHR should include all
aspects of healthcare including medical, dental, hearing and vision.
Q6 - How do you use a PHR?
A6 - You will probably find all or most the information you need
to collect for your PHR. It is probably scattered and unorganized
in a variety of places - your parents, your files, your doctors,
etc. Once you gather it and put it all in you PHR, it will be easy to
find and maintain going forward.
update the PHR with any new information when you get it.
a bound book or tear the perforated pages, hole punch and
place them in a 3 ring notebook format to make it easy to include
additional pages, copies of medical tests, reports, add additonal
journal pages, etc. This format also makes it easy to rearrange
or move older documents to additional notebook as
your history grows. This is your journal so, rearrange in whatever
order makes sense to you.
content includes:
updates in your personal journal pages. Better yet, take journal
pages with you to make notes immediately during each visit or
other activity.
consolidate all of insurance, powers of attorney, Medicare,
past healthcare history and other important information.
(Recommendation: This page should be placed as the first page in
the PHR for emergency personnel to find quickly.)
Known Allergies
Medical Insurance
Information
Healthcare Provider Contact Information
Family History – Parents, Siblings, Blood Relatives
Surgery or Hospitalizations – Serious Illness or Injury
Vaccinations and Immunizations – Child, Adult
Other Hospitalizations/Pregnancy
(optional cross reference – see Journal pages)
Dental Records (optional cross reference – see Journal
pages)
Development and Identification
Photographs
Finger Print Record
vital signs, weight/height averages, cholesterol ranges and
other common health questions. You’ll also find:
the future.
completing your PHR
(Note: The source of the enclosed reference materials, listed below,
is from MedlinePlus.gov (A service of the National Library of Medicine
& the National Institutes of Health). Please refer to the
Medline Plus.gov website and consult your doctor for additional
information.)
Temperature
Breathing
Blood Pressure
Pulse/Heart Rate
Glucose Levels
(websites)
Why should you use a Personal Healthcare Record?
Who should use a Personal Healthcare Record?
How do you use the Personal Healthcare Record?
5 Simple Steps [on how to use your PHR]
Testimonials
Template Pages (Hint: Do not write on templates/Photocopy
and keep for future use.)
Journal Page
Symptom Journal
Cover and Spine Art (For additional notebooks)
designed to offer medical advice or replace your doctor’s
healthcare advice or records. It is intended as an
organizational system only.
your PHR and putting it to use in taking charge of
your healthcare future.
u Complete Medical History section - continue to search
for missing information from other sources.
- each of your next healthcare appointments
- or, to record any illnesses, injuries or
complications
that is ok, you should begin to collect Concerns/Questions
to discuss with your healthcare professional. Most
healthcare professionals appreciate it if you come in with
a list of questions to make the appointment time more
efficient and make sure that all of your concerns and
questions are addressed.
w Record appointment information as soon
possible, preferably during appointment. Make sure you
complete the journal page with Diagnosis, Actions Needed
and Outcome and follow through on any of the actions you
need to complete.
behind the appropriate appointment in the Journal pages.
y Schedule any future appointments, tests, etc. based
on the recommendation of your healthcare professionals.
Don’t forget to schedule the routine appointments like
annual physicals, dental, hearing and vision check-ups.
Development Background for the
Personal Healthcare Record (PHR)
The author, Charla Spence, is not a healthcare
professional which makes her uniquely qualified for
developing the Personal Healthcare Record (PHR).
In the evaluation of her own needs, the needs of her
elderly parents as well as her own family, it became
obvious that some organization of this information was
greatly needed. She developed a system to personally
organize records for multiple individuals, in separate
records, which became the testing ground for what is now
the PHR system. Overtime, she found it to be a valuable
tool. She also determined would be easier if the record
began at birth instead of later in life.
Rather than lots of lengthy content explanations, medical
jargon and awkward documenting methods, Charla
provides only the most commonly used reference
information, presented in non-medical layman's terms
using a flexible, easy to use journal format.
This format is extremely important to the efficiency of the
documentation. While electronic documenting seems
logical, it isn't as efficient or practical as the handwritten
journal format for tracking health care history for several
reasons:
- In order to record information in a timely manner (before
it is forgotten), the information should be written down as
it is happening. That way the user won't forget what the
healthcare professional really said or need to find the time
to enter into a electronic system. Sometimes the best
technology is low technology!
When test results or other documents are received from
health care professionals, the user can just punch them
and place them in the journal style notebook immediately.
No need to scan as in an electronic format.
- It is portable which means it can go with the user on
vacation, be handed to a caregiver, grabbed in an
emergency; and, there is no need to be concerned about
software compatibility or even computer access.
- The notebook format allows the user to rearrange records
in a manner that makes sense to them, archive older
records in another place to make the volume manageable
and add reference information that is relative to the users
situation without carrying around information that they
don't need.
