Expert Health Articles

File Preparation for Medical Visits

One of my friends asked the other day about how he could file his advance directives, specifically durable power of attorney and living will, with the hospital to be used in emergencies. In addition, there are many different pieces of information that would be helpful whenever someone comes to a hospital, emergency room or sees a physician.

We begin with what the primary problem is or chief complaint. It is helpful to write down the problem, what are the symptoms and what are your concerns and questions, so that nothing is missed in the encounter.

Then, the following questions may be asked, such as:

Do you have any chronic diseases and how long have you had problems, current and past?

Have you had surgery in the past; did you have any problems with the anesthesia during that
surgery and/or any bleeding difficulties?

Have you been in the hospital before and for what reason?

Do you have any allergies and if so, what type of reaction?

What medications are you taking, doses or problems? What prior medications have been used, especially steroids? Be sure to include all over the counter medications.

What is your vaccination status, especially for COVID-19 and tetanus (update every 10 years)?

Do you use alcohol or tobacco and in what quantities? Have you had addiction problems that we should be aware of?

Your family history may be very important, especially if there are known problems genetically that could contribute to hospitalization or disease states. We will also then review your bodily systems, looking for clues that might be related to the current problem.

The availability of advance directives or specifically a durable power of attorney or living will in cases when the patient is incapacitated to make decisions is important. One may be unconscious from trauma, sepsis or a stroke. Having the immediate availability of the above information helps decision making and appropriate care. A durable healthcare power of attorney permits a designated surrogate to make decisions for the patient until he or she regains mental capacity. These documents can often be filed at your provider’s office or record department.

Also, it is worthwhile to investigate using an electronic website that offers personalized and secure online access to portions of your medical records. This enables you to securely use the Internet to manage and receive information about your health and can provide access when traveling.

In general, the above information is a highly recommended practice for most, if not all people. This allows for medical information to be available quickly, especially in the emergency room, if a crisis occurs. I would encourage everyone to discuss their wishes with family. Medical personnel must rely on family or friends quite often to make determinations of care. Rest assured that if we don’t have information, we do everything possible to improve the situation and save lives.

William Kose, MD, JD
Vice President of Special Projects
Blanchard Valley Health System