Three Necessary Documents for Every Physician Visit

One complaint I hear often from clients regarding their physician appointments – and it’s one that I have experienced myself on multiple occasions – is the number of times we are asked to answer the same questions, over and over and over again. Whether alone or with a client, I purposely arrive half an hour in advance of the scheduled time because I know how much paperwork we’ll be asked to complete.

“I just gave that information the last time I was here” or, “My primary care physician has all of that information,” are both frequently mentioned.

I know that electronic medical record systems are becoming more prevalent and they will eventually ease the burden of having to compile our information multiple times. For now, however, the inconsistency between healthcare systems and physicians’ offices (even within the same system) is mind-boggling. It’s also frustrating, in that it places the burden on the patient to accurately relay and verify personal data. When someone is feeling poorly or is of advanced age, the experience can provoke feelings of anxiety.

Last month, I talked about the importance of creating and bringing an agenda with you to all doctor’s appointments. Today, I suggest two additional tools to have at the ready, whenever you arrive at your physician’s office: your Medical History and your Medication List.

Medical History

The simplest way to compile and keep track of your history is in an Excel spreadsheet. But I assure you, any list you make will do.

Your list doesn’t need to be fancy or perfect, nor does it need to use “correct” medical terminology.This is a tool to help you relay information to a physician, so what matters most is that it has meaning for YOU.

Click here for a sample; it’s one I compiled recently for a client. She’s a 90-year-old woman with a lengthy history so I broke her medical conditions into sub-categories. But all that is really required is a breakout of Medical Conditions, Surgeries and Hospitalizations.

In this client’s case, and following a recent hospitalization, we added four new specialists to her team of physicians. That meant that in addition to her primary care physician and her cardiologist, she saw a pulmonologist, a nephrologist, an endocrinologist and a neuro-ophthalmologist.

Your list may be less involved, but either way, a list like this is invaluable as one moves from appointment to appointment.

Medication List

The second tool I recommend is a detailed list of medications. There are numerous online tools out there to help you and, depending on how electronically savvy you are, you can find lots of options.

But here as well, what matters is completeness and ease of use, rather than sophistication of the tool. Many of my clients don’t even use e-mail or a computer. Paper is perfectly fine, so long as the list is well-organized, easy to read and revisable.

Click here for a sample. As you can see, there is a lot of detail – the kind of information that I find very helpful when having a discussion with a physician about medical conditions and history, or when adding/changing a medication.

The list contains general categories, including:

  • Demographic information such as name, date of birth, allergies and revision date
  • Daily Medications
  • Vitamins, Herbal Medications & Nutritional Supplements
  • Occasional/As Needed Medications
  • Previously Taken Medications

When listing each medication, this is what you should include:

  • Medication name
  • Condition for which it is used
  • Who prescribed it
  • Date it was started (and date ended on list of previously taken medications)
  • Dosage
  • How often you take it/frequency
  • Notes

Often, when I compile this with a client for the first time, there are medications identified for which the condition is unknown. This becomes a teaching opportunity for me, as compiling the Medication List usually necessitates revising the Medical History, because a condition for which a medication is being taken was inadvertently omitted.

When you arrive for your doctor’s appointment, make sure that you bring extra copies. If you are asked to complete a form that asks for medications, just write “see attached” and include a copy.

You’ll also find this document handy for those appointments in which you are asked to review medications for accuracy. No need to remember the details when you’ve got it all printed out and in your hand!

[By the way, make sure any changes you make are reflected in your medical record for next time. This is particularly important if your next visit is in the emergency room that may lead to an admission. Depending on the office, a medical assistant or the physician may take responsibility for making the changes, so always mention it before you leave: “I found several inaccuracies on my medication list and revised it in detail. Can you assure me changes have been made in my electronic medical record?”]

So that’s what you need – the essential trio of “bring along” documents for every physician appointment: A written agenda, your medical history and your medication list. Start putting these together now and watch how smoothly your next visit unfolds!