You arrive on scene to find an 87-year-old female lying on the floor next to her bed. The woman’s neighbor was forced to use a duplicate key to access the patient’s apartment because she had not been responding to her phone calls. Upon arrival, you note the patient is confused and mumbling incomprehensibly. The neighbor tells you that she knows virtually nothing about the patient’s medical problems.
What happened to this patient? What is her medical history and what bearing might it have in regard to the patient’s presentation? Who is her next of kin and how can they be notified?
Fortunately, the patient carries around an electronic flash drive around her neck, which contains all of her medical records and contact information in case of an emergency. Your crew immediately inserts the drive into a laptop computer in the ambulance and gains instant access to the patient’s medical history.
This is just one example of how on-scene access to patient information can be vital to patient care and the importance for EMS personnel to promote this concept in their communities. Thus, it was no surprise when the American College of Emergency Physicians (ACEP) asked me for my input in developing an Electronic Patient History Form that could be stored on a jump drive or some other media. This form was to be primarily targeted at the geriatric population since this group typically tends to have the most complicated and in-depth medical problems. They are also the group to most likely require EMS activation.
So, I came up with a sample medical history based on a composite of patients I have cared for over the years in the emergency department. Now for you HIPAA nerds out there (and you know who you are), you can be rest assured that all proper documents were signed, sealed and delivered before I created the sample history.
While the information contained in this column’s Sample Form is submitted with a small dash of humor, the concept behind the form is very relevant to EMS providers, as well as emergency department staff caring the ill and injured. Currently, most patients do not have any formal documentation of pertinent medical details (in either electronic or paper format). When we are fortunate enough to encounter a patient who actually possesses their own medical history documentation, it suddenly makes both the lives of the provider and the patient much easier.
In this day and age, we tend to want to digitize all our information so that we can utilize it on a computer. So, the Electronic Patient History Form is born from that bias. Obviously, any reasonably accurate documentation (paper or otherwise) a patient possesses is a significant advantage. I am virtually certain vendors are already working on some type of electronic form — although I am not specifically aware of which companies. All of us involved in the emergency care of patients should encourage the development and use of such products, because they will enhance and simplify our patient encounters while providing an extra margin of safety for the patient.
Presently, the Electronic Patient History Form seems to be languishing somewhere deep within the bowels of ACEP, for reasons which I am not really sure of. I have yet to receive any communication back from ACEP on this brilliant idea. Perhaps they didn’t embrace the concept as enthusiastically as I would have hoped.
So in an attempt to re-invigorate the idea, I am presenting the sample history in this column for your consideration. OK, I know it’s not exactly the new EMS product trial that I promised this column would be — since my idea has not yet been trial tested by anybody. But you never know … I may be deluged with interested customers after this column runs.
I’ve also included some of the sample patient’s family contact information and some heartwarming pictures that demonstrate how easy it is to personalize and customize the Electronic Patient History Form to best suit your purposes.
(By the way, all addresses listed in the sample medical history are located in the State of Ventricular Fibrillation, VF)
Sample Patient Medical History Form
Name:
I.M. O’Shyster
Date of Birth:
11/20/1931
Occupation:
Retired
Former personal injury attorney
Medical History:
Heart disease (heart attacks in ’81, ’92, ’98, ’03, ’06)
Irregular heart beats due to long QT Syndrome
Stroke with mild left-sided weakness after last heart surgery
Congestive heart failure
Diabetes
High blood pressure
Lung cancer (in remission) due to second hand smoke
Arthritis
Chronic fatigue syndrome
Fibromyalgia
Recurrent bladder infections
Herniated discs at C4,5,6 — as a result of a car accident
Surgical History:
Cardiac Bypass: 1982, 1998, 2004
Angioplasty with stents in: 1993, 2006
Cervical Disc Surgery: 1989 and 1997
Hysterectomy: 1986
Silicone breast implants: 1979
Gall Bladder removed: 1972
Current Medications:
Betapace 140 mg twice a day
Amiodarone 600 mg once a day
Propanolol LA 120 mg twice daily
Fursosemide 40 mg twice daily
Vioxx 25 mg once a day
Diabinese 500 mg once a day
Seldane 1 tablet twice daily for allergies
Levofloxacin 500 mg once a day to prevent occurrence of bladder infection
Droperidol 5 mg two — three times per day as needed for nausea
Prednisone 10 mg twice daily as needed for fibromyalgia pain
Amitriptyline 50 mg at night as needed for sleep
Oxycontin IR 160 mg tablets two – three times a day as needed for pain
Oxygen 2- 4 liters per minute as needed
Allergies:
Latex
Codeine
All “cillins”
Toradol
Recent ECG:
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Recent Chest X-Ray:
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My Personal Physicians:
Primary: U.R.A. Quack, MD
Phone: 555-555-5555
Email: Tortdeform@godhelpus.com
Address: 5555 Impaired Road, Titanicberg, VF 66666
Cardiologist: Ida B. Greede, DO
Phone: 555-555-4444
Email: havecathwilltravel@fleece.com
Address: 3333 Ripoff Street, Suites 301-910, Yikestown, VF $$$$$
Oncologist: Constantine E. Morose, MD
Phone: 555-555-2222
Email: drdeath@weplantem.net
Address: 2222 No Chance Avenue, Research Trial, VF 99999
My Preferred Ambulance Drivers:
Name: Paragod Ambulance & Mortuary Service
Phone: 911-919-9119
Email: cowboys@taxicab.net
Address: 911 Noair Way, Anoxia, VF 91111
My Preferred Hospital:
Name: Temple of Doom Hospital Medical CenterPhone: 555-555-0000
Email: litigation@EMTALAviolations.org
Address: 00000 Boris Karloff Blvd., Auschwitz, VF 11111
In Case of Emergency Please Notify:
1. Casper M. O’Shyster
Relationship: Husband
Phone: 555-555-3333
Email: insuranceusedup@endless.com
Address: 2233 “A” Devastation Drive., Calamityville, VF 00000
2. Leech N. O’Shyster
Relationship: Son
Phone: 555 555-3333
Email: neverlefthome@totallyworthless.net
Address: 2233 “B” Devastation Drive., Calamityville, VF 00000
3. Goddess O. Wonder
Relationship: Daughter
Phone: 555 555-9999
Email: pickled@fadingbeauty.com
Address: 6612 Plastic Place, Botox City, VF 22333
Family Pictures:
| The Grandkids | ||
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| Our Dawgs: Larry, Moe and Curly |
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| My son Leech, just before going to church | My husband Casper, on his way to work | |
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Like the day of my high school prom, I’m just sitting by the phone and waiting for that call.
| Want a copy of the Sample Patient Medical History Form to pass around your crew quarters? Then PRINT the column today! |
