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Understanding the Importance of Medical History

Medical records

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As a direct support professional, part of your job is to ensure that the individuals you support are able to maintain the best possible health. One of the best ways you can help people stay healthy and strong is by understanding their medical histories. When you understand and document an individual’s medical history, you help to assure that you and the individual’s health care providers provide the most appropriate and effective treatment and support for the individual’s illnesses and health conditions so that they maintain the best possible health.

What is a medical history?

A person’s medical history is made up of many different pieces of information that tell the complete story about that individual’s current and past health. A complete medical history record should include information on the person’s:

  • Diagnosis – for instance, if the individual has been diagnosed with mental retardation, cerebral palsy, depression, diabetes, hypertension, or any other medical or mental health conditions.
  • Known Allergies – a list of any allergies that the person has, such as allergies to medications, foods, or bee stings.
  • Current Medications – the names and doses of any medications the person currently takes.
  • Past and Present Illnesses – information on any serious or chronic illnesses the person has experienced; for instance, if the individual has ever had tuberculosis or if the individual has asthma or diabetes.
  • Medication History – a list of medications that the person used to take, as well as information about when these medications were started and stopped.
  • Current Doctors – names, phone numbers, and specialties of the individual’s current health care providers, including doctors, dentists, mental health specialists, and any other health care professionals.
  • Emergency Contact Information – names and phone numbers of family members or others to call in case of an emergency.
  • Previous Surgeries – information on any surgeries the individual has had.
  • Previous Hospitalizations – dates and reasons for any previous hospitalizations.
  • Family Medical History – information on any health conditions the person’s close family members have been diagnosed with, including conditions such as cancer, heart disease, and mental illnesses.
  • Immunization Records – information on immunizations that the individual has received, along with the dates that the immunizations were given.
  • Insurance Information – health insurance member identification number and contact information.

These pieces of information may come from many different sources, but by compiling them into one document or folder, you can make sure that these important records are easily accessible to you, the person you support, and the person’s health care providers.

This worksheet may give you a starting point for assisting the people you support in putting together their medical history records.

Remember, this sheet can be filed in a folder with other medical documents to form a complete medical history record.

Since a person’s medical history can change over time, it is important that you assist the person you support in keeping his or her medical history record as up-to-date as possible. Any time an individual is diagnosed with a new health condition or starts taking a new medication, this should be noted in their medical history record.

Is a medical history important for individuals with developmental disabilities?

It is important for everyone to keep track of and document their own medical history, but this can be especially important for individuals with developmental disabilities.

  • People with developmental disabilities often see many doctors and take many medications. By documenting their medical histories and keeping them up-to-date, individuals can help each of their doctors know what the others are doing, and help avoid dangerous medication interactions.
  • Also, some people with developmental disabilities may have trouble communicating verbally. In these cases, a written medical history can ensure that health care professionals are able to easily and quickly access all of the information they need to provide the proper treatment, especially in an emergency.

How can keeping track of a person’s medical history be helpful to me?

A medical history is useful for many reasons. As a direct support professional, an individual’s medical history can help you to:

  • Know which medications the person takes and provide assistance with self-administration of medications.
  • Know if an individual is allergic to certain things so that you can assist the person to avoid those things he is allergic to.
  • Provide proper first aid – for instance, you would need to respond differently to a bee sting depending on whether or not the person who was stung is allergic to bees.
  • Respond to an emergency – by knowing an individual’s medical history and keeping a medical history sheet or folder in an easily accessible location, you will be able to share this information with emergency personnel quickly; this can ensure that paramedics and emergency room doctors have all the information they need (such as allergies, medications, and diagnoses) to treat the person’s condition in the best way.
  • Respond to new signs or symptoms that you observe – by understanding a person’s past conditions, you can tell if symptoms they complain of are part of an already diagnosed illness or brand new issues; for instance, if a person who has been diagnosed with asthma is having trouble breathing, you will know to give this person his or her inhaler, but if an individual who has never been diagnosed with asthma is beginning to cough or wheeze, you may need to take this person to see his or her doctor for a diagnosis.

How is a person’s medical history helpful to other health care professionals?

One of the most important things that you and each individual who you support can do with their medical history is to share it with health care providers!

  • A written medical history can be easily shared with emergency personnel. Emergency room doctors and paramedics need to know which medications the individual is taking as well as their health conditions and any allergies that they have in order to provide safe and effective treatment.
  • A written medical history can also be easily shared with any new health care providers the individual is visiting. Each of an individual’s health care providers needs to know what treatments and medications other doctors have provided. By knowing this information, doctors can avoid duplicating services and also avoid dangerous interactions between medications.

What should I do?

As a direct support professional, you can assist and encourage people with developmental disabilities and their families to compile their medical history into one document or folder. You can also become familiar with each individual’s medical history and use this information in your work – to assist the person with self-administration of medications, to help the individual to avoid things that he or she is allergic to, and to react correctly in cases where first aid or emergency care are needed.

In addition to assisting people in making a sheet or folder with their medical history, you can encourage individuals with serious allergies or health conditions to put this information on a medical alert bracelet. By listing their more serious conditions or allergies on a bracelet, individuals can ensure that emergency medical personnel are aware of this information before any treatments are started. For example, if a person is allergic to a medication, it is critical that emergency medical personnel know this immediately, before they begin their treatment.

You can also remind the people who you support to share their medical history during their first appointment with any new doctors and before any new medications are prescribed. Knowing a person’s full medical history can assist doctors greatly as they work to treat the individual.

Where can I go for more information?

You can use this presentation to educate the people who you support about what a medical history is and why it is important.

You can also check out these resources on the web:

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Last updated on Fri, 06/11/2010 - 17:42