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In mobile world, keep own medical records

(ran HT, CI, PT, SP edition)

Picture this: You are in a hospital emergency room with what appears to be a serious bacterial pneumonia. The emergency room physician wants to start you on an intravenous antibiotic immediately.

The drug's name has a familiar ring, but is that because it's the same one that gave you heart palpitations a few years ago? In your fevered state, you can't remember.

A nightmare scenario? Unfortunately, in this world of continent-hopping business and pleasure travel, it is an all-too-plausible emergency, according to the American Health Information Management Association.

AHIMA, representing 30,000 workers who capture, code and analyze hundreds of thousands of patient records in HMOs, nursing homes and hospitals, says it's time we all became more responsible medical consumers.

"We are urging everyone to take a few moments to record their vital medical information and to take a copy with them when they travel," said Jack Segal, a spokesperson for AHIMA.

An easily accessible record is especially important in an age when people change jobs, health plans and locations fairly often. "Having your own record in hand can ease transitions between health providers greatly," Segal said.

It's also critical that doctors, nurses and other health providers have access to current, specific information about the patients they are treating, said AHIMA president Merida L. Johns.

"Many people are under the false impression that emergency room staff can access a data base at any time which contains all their important medical documents," said Johns. In reality, few hospitals or nursing homes have such data on-line.

Another mistake consumers make is to believe that their doctor will be able to find old records quickly and get them to another doctor who needs them.

In reality, many doctors run out of storage room and keep old documents at some remote location. Or a physician may retire, sell his practice, move away or die.

In addition, most people visit different doctors over a lifetime _ an internist or allergist, an obstetrician/gynecologist, an orthopedic surgeon, a heart specialist _ and no one doctor keeps track of what the other specialists are doing or what medicines they are prescribing.

"This is where the patient's own records are critical," says Segal.

To promote patient education and patient responsibility, AHIMA has developed a four-page health form and is providing it free of charge.

It urges consumers to fill it out _ in pencil _ as completely as possible and make several duplicates. "Give one to your spouse, your family doctor and keep one in your glove compartment or your suitcase when you travel," Segal said.

Having such a record at hand can speed diagnosis and reduce the chance of unnecessarily duplicating expensive tests that were already done.

It can serve as a handy inoculation record, so you can make sure you have all the necessary shots when you travel.

Of course, records like these are useless unless "other people know about them. So, broadcast their existence," Segal said. And update them when there is new data.

If you are hospitalized, don't ask for a complete file when you leave as this "could amount to several hundred pages," Segal said. Instead, make sure you get something called the discharge summary, which gives the doctors' final assessment of your condition.

Also get all pathology and lab reports as well as copies of pertinent X-rays.

Other tips:

Call your doctor's office and work with staff there to complete the form if there are portions you are unsure how to answer. Ask them to send copies of important evaluations or tests.

Keep a file of all medications you take, prescription and over-the-counter, and give the list to one pharmacist. That way, he or she can spot possible drug problems and avoid adverse interactions.

Keep copies of medical, hospital and pharmacy bills even if you are insured. These documents can be used to challenge insurance company rulings or inadequate reimbursement by Medicare.

Consult family members to build a comprehensive medical history about yourself and other close relatives. Note family longevity patterns on both sides of your family as well as any history of diseases such as cancer, diabetes, high blood pressure, emphysema, alcoholism, heart disease and dementia.

_ If you are concerned about privacy, make it clear that you do not want duplicates made of your health form without permission.

To get a free health form, send a self-addressed, business-size envelope with 55 cents postage to AHIMA, 919 N Michigan Ave., Suite 1400, Chicago, IL 60611-1683.

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