Be Responsible and Document Your Health-Assists Drs. with Diagnoses & Need for Less Tests

Quality-Improvement-Health-Care-main Healthcare costs would improve if we all were better scribes of our own health. By this I mean, in documenting symptoms and precipitating factors related to events, medications we take, personal histories/habits, as well as our family histories; all of which are necessary pieces of information Doctors need in making their diagnoses. The less information the Doctors are given, the more tests they have to order to be able to rule out  disease processes, which isn’t cut and dried, as a lot of disease processes overlap one another and present with similar symptoms. It also takes more time on the healthcare team’s part when all the information isn’t there.

Let me give you an example of how things are missed when information isn’t shared. A person comes in with complaints of chest discomfort, nausea, no relief noted with Advil and symptoms occurring off and on for last several weeks. He or she FAILS to tell the physician that there is a past history of gastritis, the discomfort always occurs after eating and that he or she really partied hard the night before. There is no stated family history of heart problems. The physician tries to obtain as much information as possible on his or her own, but critical pieces of information weren’t communicated by the patient, for whatever reason. The scenario will most likely leave the physician no choice other than to order necessary tests  to rule out specific diagnoses. Without enough information to make a definitive diagnosis, the physician will most likely request the patient see a specialist for further workup of his heart to rule out underlying disease.

If the person with the problem had written down all information, including, but not limited to, specific symptoms, precipitating factors, current health history, habits, medications and family history, the physician most likely would have been able to make a more definitive diagnosis, without having to order additional tests or refer to a specialist. Healthcare costs are not cheap as we all know.There are times when people have acute situations where Emergency Rooms visits are necessary. It is during these visits that information isn’t always available secondary to the patient and their status. If people were to carry around this information in their wallet or purses, it would save so much time as well as lives in some cases. Time spent gathering the necessary information for diagnosis would be spent treating people instead.

Sometime the lack of communication may be secondary to language barriers, which would be less of a problem if family members were able to present with the patient. In my decades in the healthcare business, I can tell you that there are also many who merely drop off people scheduled for an appt., without sending in or providing any information at all. This is typically seen at appointments for older children or elderly patients. Because of such scenarios, appointments have to be rescheduled, which can cause issues between  families and Doctors’ offices; all because someone was trying to take shortcuts and wasn’t prepared. This is also a waste of the healthcare provider’s time, which could have been spent helping someone else.

A part of the overall healthcare costs are secondary to a lack of responsibility on the part of people in communicating related information. This blog is not to point fingers, but merely to inform everyone that their part in gathering their own personal or family members’ information, will greatly help medical personnel in diagnosing and treating problems as well as help keep tests and costs to a necessary minimum. A Win-Win for all.



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