Sharing your medical history with clinicians

It is often assumed that the person carrying out a consultation has acces to your medical records and your full medical history. Sometimes telephone consultations are carried out with a clinician who doesn’t know (or have access to) your medical history.

This is quite common. As we get older and are likely to have more than one medical problem (‘multimorbidity’ in jargon), and services are frequently delivered by different specialists from a variety of different professions (‘sub-specialisation‘ in jargon).

If we have a medical condition that has been ongoing for many years and is well controlled, we may forget to tell the clinician. You may forget to mention something like asthma for example, because it hasn’t been problematic for a while. It’s really important not to miss these areas, as the safety and effectiveness of your treatment plan depends on it.

It may help, before the consulation, to write a list of:

  • Previous illnesses, including mental health problems*, sleep problems and mood variations (‘no health without mental health’)
  • Previous hospital admissions & operations
  • All your long term conditions (the chart below shows an acronym ‘MJTHREADS’ used by clinicains). Alternatively it may be helpful to think of a ‘systems review’ in terms of a ‘body scan’, starting with the head.
  • All health related people (including complementary therapists, & support groups ) that you see.

In addition some (or all) of the follwing details will be relevant. Think about:

  • Your prefereneces and beliefs about treatments, including rescussitation & end of life care (often called advanced decisions or advance care plans)
  • Who cares for you or who you care for. People don’t always realise (or tell clinicians) that they are caring for others
  • Your job or lack of a job , or how you occupy your time
  • Financial worries
  • Your social circumstances – who do you live with? -do you have close family & friends? -do you feel isolated? -live in a remote loctaion? – do you feel vulnerable? – your hobbies?
  • How you feel about your own safety – have you ever felt like harming yourself?
  • Past (or recent / ongoing) trauma and abuse
  • Your spiritual beliefs
  • Recent travel abroad
  • Your ethnicity
  • Your diet and any recent changes
  • Recent weight loss or weight gain
  • How much exercise you take
  • Your sleep pattern and any recent changes
  • Your family history
  • Other areas (listed here in no specific order) such as childhood history, preganancy history, risk taking history or sexual history

*In response to feedback on this blog from patients, it’s important to note that there may be some details related to mental health that patients do not want to share with all clinicians.

The above list may look daunting, and is obviously not all needed in all consultations, however it’s worth reviewing. I have come across people who were waiting to be asked some of the above questions, and wanted to tell someone something important, who told me they only opened up because they were asked.

This blog links to the blog for patients on making the most of telephone consultations. It’s a ‘rolling blog’. I will be updating it based on feedback, and incorporating all coimments and suggestions.

Steve Turner is a nurse prescriber and clinical educator & Associate Lecturer at Plymouth University. Steve shares health information from the Twitter account @MedicineGovSte using hashtags: #TeamPatient #TeamNHS #TeamCOVID19  and on the web site www.patientled.education

Click here for the Care Right Now CIC web site

If you have any questions about coordinating care for a loved one, you can contact Steve by email: steve@carerightnow.co.uk

Published: 01.05.2020

Author: Steve Turner

Version: Draft 1b 11.05.2020

Revision history: Asterisked note on patients’ preferneces for data sharing inclided.

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