This Personal Health Record Is for Your Own Use

MSK Initiative – Personal Health Record – Version 10

MY PERSONAL

HEALTH RECORD

This Personal Health Record is for your own use.

Please show it to your family doctor and other health care professionals.

If you need help with reading or understanding the Personal Health Record, please ask a family member or friend to assist.

If found, please call:

______

NameTelephone

ALLERGIES and REACTIONS:

Medication:

______

Food:

______

Seasonal:

______

INTRODUCTION

About the Personal Health Record

You and your caregivers can use the Personal Health Record to help manage your health care.

Why use this Personal Health Record?

You can use the Personal Health Record to store information about your health in one place. This information will allow you to track changes and help you make decisions about your health care. It will also help you when talking with your doctor or other health care providers.

How to use this Personal Health Record

Use this Personal Health Record in the way that works best for you – there is no right or wrong way. For example, you may wish to keep notes in every section of the Personal Health Record, or only those sections that have meaning for you. Using the diary section to monitor your pain or other symptoms may help you decide if it is time to see your health care provider. Keeping notes of what has worked or not worked in managing pain or other symptoms will also help when talking with your health care provider.

What is self-management?

You are already self-managing your health care in the choices you make every day. Self-management activities include taking your medication, getting enough sleep, monitoring your symptoms, exercising, eating well, getting emotional support when needed, or what you do to learn about any conditions you may have.

Self-management does not mean you have to do everything by yourself. Your health care team can provide you with support and guidance as you manage your health care.

More Information

The back of the Personal Health Record contains more information on the various sections of the Personal Health Record, including how to record medications and supplements, how to decide when to visit your doctor and how to prepare for visit with the doctor.

PERSONAL AND HEALTH CARE TEAM INFORMATION:

Name: ______

Address: ______

Phone: ______

Cell Phone: ______

Emergency Contact: ______

Phone:

Advanced Directive: ______□ Yes______□ No

If yes, copy located at ______

Representation Agreement: ______□ Yes______□ No

If yes, copy located at ______

Family Physician: ______

Phone: ______

Specialist: ______

Phone:______

Specialist: ______

Phone:______

Pharmacist: ______

Phone:______

Other Health Care Providers (e.g., physiotherapist, massage therapist, etc.):

Name: ______

Phone:______

Name: ______

Phone:______

Name: ______

Phone:______

Name: ______

Phone:______

MY HEALTH CARE APPOINTMENTS (Record these on the Back Page)

List of Terms

Advanced Directive:

An Advance Directive is a legal document in British Columbia for writing health care instructions.

Representation Agreement:

A Representation Agreement is a legal document for personal planning in British Columbia. It is a way to authorize your personal supporters to help you manage your affairs or make decisions on your behalf if you need assistance due to illness, injuryordisability. A Representation Agreement is the only way to authorize someone to assist you or to act on your behalf for health care and personal care matters. It can also cover routine financial affairs and legal matters.

For more information on these terms, please go to

MEDICAL CONDITIONS/SURGERIES:

Record any medical conditions you have been diagnosed with, past and current, as well as any surgeries you have had. See page 13 for more information.

Surgery/

Conditions/SurgeriesDiagnosis Date

______

IMPORTANT TEST RESULTS: (e.g.: blood, urine, radiology). See page 14 for more information.

Name/TypeDateWhy TestedResult

______

MEDICATIONS AND SUPPLEMENTS:

Record all medicines and supplements you take (all prescription & non-prescription). See page 13 for more information.

Medication/Supplement Name / Reason for taking/ Prescribed by (if applicable) / Dose/
Time of Day / Date Started / Date Stopped/ Why
Example: medication name / To control joint inflammation / Dr. Smith / 50mg
Morning / Jan 1, 2009 / Dec 30, 2009
Severe nausea
Medication/Supplement Name / Reason for taking/ Prescribed by (if applicable) / Dose/ / Medication/Supplement Name / Reason for taking/ Prescribed by (if applicable)

PAIN DIARY: (Describe your pain here)

Record where you feel pain (e.g.: left knee, both shoulders, middle finger right hand), when it happens and what it feels like. See page 14 for more information.

DateDescribe the Pain (where, when, what does it feel like…)

______

GENERAL HEALTH DIARY:

Record the date and details of changes in your general health, sleep, activity and independence and your mood and emotions. See page 14 for more information.

DateObservations

______

NOTES FOR NEXT HEALTH CARE VISIT:

List items to discuss at your next medical appointment, e.g.: symptoms, concerns, medication requests. See pages 16 for more information.

______

REMINDER FOR FUTURE MEDICAL TESTS:

Use this section to record future medical tests recommended by your physician. See page 16 for more information.

Year of TestName of TestReason for Test

______

MY ACTION PLAN:

Note: See pages 19 for more information on how to use this section.

Record what you will do, how much you will do, when you will do it and how often.

Record your confidence level in completing the goal, for example: 0=No Confidence to
10=Very High Confidence. Record action plan results in your General Health Diary.

Date / Action Plan / Confidence Level
Date / Action Plan / Confidence Level

YOUR HEALTH CARE TEAM

Your health care is a team effort between you and your care providers. These can include a family physician, specialist, physical therapist, nurse, psychologist, social worker, occupational therapist, massage therapist, naturopath, and many others.

MEDICAL CONDITIONS & SURGERIES

Record any medical conditions you have been diagnosed with, past and current, as well as any surgeries you have had. This includes conditions that may not be present all the time, for example, asthma that may only occur during certain situations. This informationis helpful to health care providers you are seeing for the first time.

MEDICATIONS AND SUPPLEMENTS

Medications

It is important to know why you are taking each medication, and how to use each one correctly and safely. Your doctor is the first person to discuss any questions you may have. Your health care team and pharmacist are also good sources of information and advice.

Ask enough questions to make sure you understand your medication, such as:

Name of the medication, the reason for taking it and how it helps your condition
When you need to take it and what to do if you miss a dose
What foods or beverages to avoid while taking this medication
What the possible side effects are, and what to do if they occur

Supplements

It is important to tell your doctor or pharmacists if you are using supplements as they may interact with your prescription or over-the-counter medications. These include vitamins, minerals, herbs and other supplements. Record supplements with your medications.

Information about supplements and how they might interact with other medications you may be taking can be found at:

CAMline –

CAMline is an evidence-based website on complementary and alternative medicine (CAM) for healthcare professionals and the public.

Natural Standard –

Natural Standard was founded by clinicians and researchers to provide high quality, evidence-based information about complementary and alternative therapies.

TEST RESULTS

(e.g., blood pressure, glucose levels, etc.)

Blood, urine, radiology, and other kinds of tests are useful in helping to diagnose one’s medical condition. They can also be used to track how well medications and other treatments are controlling or managing your disease.

Ask your physician what tests are commonly used to diagnose or track how well your disease is being managed.

For a description of common tests, check out HealthlinkBC at

PAIN AND GENERAL HEALTH DIARY

Keeping a record of how you are feeling, changes in your health, how your health is impacting your quality of life and how you are responding to treatments will help in the management of your condition. It is helpful to track changes in your general health, your pain level, your sleep, your activity and independence, and your mood and emotions. This gives your health care provider valuable information about how your condition is affecting your day-to-day life. Remember to note things that may affect how you are feeling, other than your condition.For example, you may be feeling good because you have been on holiday, or you may be depressed due to the death of a pet.

Your health care provider may give you other tools that will help you track items such as pain, if you have a fall, or your mood.

VISITING YOUR HEALTH CARE PROVIDER

How to get the most out of your visit

Being prepared is the best way to get the most from your visit. Think about what you want to talk to your health care provider about and prepare a list so you do not forget. Make sure your list has the most important items at the top as you may not have time to get through all of them in one visit. Eight questions you may want to ask yourself in preparation for your visit:

What is the main reason for your visit today?
Do you have any other concerns?
My ability to manage my chronic condition
My decreased energy level / fatigue
Financial issues
Having access to health care
Emotional issues
Family issues
Spiritual support
Thinking or memory problems
End of life issues
Have you been having any problems with your medications? If so, what?
Have you stopped or changed your medications since your last visit?
Have you started any new over-the-counter treatments or supplements?
Do you have medications to be refilled? If yes, please list.
Do you have any recent lab results or X-rays to go over?
Do you need any forms signed, or do you need a note today? If yes a charge may apply.

Questions you may want to ask about your medicines:

What does this medicine do?
How long will I need to use it?
How and when will I need to take it?
What are the medicines, drinks, foods or activities I should avoid when taking this medicine?
What are the possible risks and side effects and what should I do if they happen to me?

Questions you may want to ask your physician at the end of your visit include:

What is my main problem?
What do I need to do?
Why is it important for me to do this?
Will I get better? How long will it take?

A question you may want to ask yourself is:

Do I feel confident that I could explain what I have heard today to a friend or family member?
Has the conversation below ever happened to you? If so, ask for things to be explained in a way you can understand.

REMINDER FOR FUTURE MEDICAL TESTS

Part of planning for your future includes remembering to go fortests that will assist in monitoring your health status. Tests may be related to your age or the medications you take. For example, people on hydroxychloroquine (Plaquenil) need yearly eye exams.

To find out the tests you need to have you can ask your doctor or phone the BC NurseLine at 811.

GOALS AND ACTION PLANS

Setting goals for your health

Setting goals is an important step in managing your health care. Your goal may be to manage your medical condition, to reduce risk factors to your health, or to return to an activity you used to enjoy. Work with your health care provider when setting goals. They can help you set goals that will aid in the management of your condition and return to activities.

Managing your condition

The next step in setting goals is developing an action plan with your health care provider to help you meet your goals. An action plan may include anything from taking prescribed medication, building an exercise program into your routine, changing your diet, attending an education session or doing things to manage stress.

Use your diary to record your progress with your action plan. This will be helpful in showing what has worked or not worked for you and what actions might need to be changed.

Goals

It is common to want to have the life that you had prior to your chronic illness. Although this may not be possible, your health goals can help you to be the best that you can be. Setting realistic short- and long-term goals is an important first step in managing your condition. Set a long-term goal and then break it up into smaller achievable steps, or short-term goals. For example:

Long Term Goal:

In 3 to 6 months time, I will lose 5 lbs.

Short Term Goals:

This week, I will eat at least 7 fruits or vegetable servings, 4 days of the week.
This month I will schedule an appointment with a dietitian to review my eating plan.

Goal setting tips:

Record your goals
Share your goals with friends and family, and get them involved in your plan as much as possible.
Assess your goals and change as needed
Have a back-up plan for your goals. For example, if you can’t exercise outside, consider walking in a mall.
Reward yourself! Recognize a job well done and give yourself small rewards for the goals that you achieve.

Ensure your goals are:
SMART{ / Specific enough to know exactly what you want to achieve
Measurable to know when your goal and action plan has been reached
Action-oriented to produce the results you want
Realistic so that it is practical and achievable
Time is available to achieve your action plan

Are you ready?

Your level of readiness to make change and manage your condition may vary from time to time. Ask yourself just how ready you are. For example, “am I convinced I need to change, do I understand why it is necessary?” “Are there too many things happening in my life right now and I cannot manage one more thing?” Assessing your level of readiness will help you be successful in making change. If you are ready, go for it! If you are not, understanding why will help you take steps toward change. Your health care professional may help you assess your level of readiness when you are working together to set goals and develop an action plan to help you manage your condition.

If your confidence is low, or if you encounter barriers completing your plan, try problem solving:

Identify the problem. Be as specific as you can!
List all possible solutions.
Pick one or two ideas.
Try it for two weeks. Give it a good test!
If it doesn’t work, try another idea.
If that doesn’t work, find a resource for more ideas. Maybe a friend or a professional can help.
If it still doesn’t work, accept that the problem may not be solvable now. Set it aside for now and work on something else.

(Adapted from Lorig et al Living a Healthy Life with Chronic Conditions, Bull Publishing, 2006)

My Action Plans

You and your health care provider may work together to develop an action plan of items that will help you self-manage your condition and meet your SMART goals. These may range from a visit to a specialist, treatment, starting an activity or attending an education class. It is important to monitor how you are doing with your action plan. You may need to seek help if you are having difficulty completing an action or make adjustments with your health care provider. Items may be added to your action plan each time you visit your health care provider.

MY EDUCATION AND MATERIALS

Finding education and resources

Understanding your condition and how to manage it is one of the most important things you can do as part of self-management. Your health care providers will provide you with valuable information. There are also other good sources of information available including education classes in the community, the Internet, and books and pamphlets from disease-specific societies, such as the Canadian Arthritis Society.

When deciding what information to use, you may wish to consider the following questions:

Is the author an expert in the field with recognized credentials?

Is the information up-to-date and relevant to your type of arthritis and situation?

Is the information Canadian-based?

Is the resource easy to use, with understandable, reader-friendly language?

Does the resource provide well-balanced information and avoid promises of “quick fix” solutions or “cures”?

Does the information encourage you to consult with your physician or health care team?

When you look for information on the Internet consider the source of information. Be cautious of information that is designed to sell something, such as a particular product or service. Some clues about the type of site you are visiting may be available in the Website address. For example, generally, websites that end in “.ca” tend to be Canadian sites and those that end in “.com” tend to be commercial sites. Some websites end in “.edu”, which indicates that they are an educational institution. Government websites end in “.gov”. When in doubt about the quality of any information, it is best to consult with your health care provider.