It’s your first visit to a cardiologist because you’ve had occasional episodes of an irregular heartbeat. As you fill out your pre-appointment paperwork, you carefully list the symptoms you’re experiencing and the treatments your primary care physician has recommended before referring you to a specialist. You don’t mention that you recently started taking Lexapro (escitalopram) to treat depression because you’re focused on your heart issue.
But that accidentally omitted information could shape both your diagnosis and treatment plan. One potential side effect of escitalopram is abnormal heart rhythm. Suppose the cardiologist isn’t aware you’re taking this medication. In that case, she or he doesn’t have all the information needed to make the most accurate diagnosis and recommend the most appropriate treatment plan.
An up-to-date, comprehensive medical history can lower your risk of being misdiagnosed.
Making sure you share your complete medical and family history with every health care provider who treats you can reduce your risk of experiencing a misdiagnosis or medical error. This information can be even more important in an emergency when things are moving quickly, you’re not able to speak for yourself, or if you get seriously ill or injured while you’re away from home and the care of your usual health care providers.
When providers don’t have your complete, updated medical record, you face a greater risk for a range of problems, including:
1. Medication errors and interactions. Your provider needs a list of all your prescription and over-the-counter medications and supplements. Without this information, you’re at an increased risk for medication errors. Some of these errors can have serious health consequences. For example, suppose your doctor doesn’t know that you take an ACE inhibitor for high blood pressure, and he or she prescribes a potassium supplement. In that case, the result could be a significant build-up of potassium in your blood, a condition called hyperkalemia, which can damage your heart muscle.
2. Duplicate tests and missed follow-ups. If a health care provider doesn’t know what diagnostic tests you’ve already undergone, you’re at risk of being sent to get the same tests again. This can slow the process of reaching a diagnosis. It can also carry unnecessary health risks, like exposure to additional radiation if you have repeat, unneeded imaging tests. There’s also a financial impact. Paying for unneeded duplicate tests can increase your out-of-pocket health care costs. Access to your previous test results is also important if the results suggest that you need additional testing or follow-up care. Without this information, you may not get the care you need.
3. Misdiagnosis. If your provider doesn’t have access to your complete medical record, that lack of information can increase your risk of being misdiagnosed or delay your diagnosis. For example, your provider needs the results of previous bloodwork and imaging studies to compare the results with any new tests. It’s also important to share your family medical history. For example, if a close relative was diagnosed with cancer or had a heart attack at an early age, you may be at a higher risk for these conditions.
4. Inappropriate treatment. Lack of access to your complete medical history may also raise the risk of receiving treatment that’s not appropriate for your current condition. If you’re experiencing back pain, but the provider you’re seeing doesn’t know you’ve never tried physical therapy to manage your pain and strengthen your core to reduce the risk of future back injury, he or she may recommend more intensive treatment like prescription pain medication or surgery, both of which can have significant side effects and come with a risk of complications.
To help make it easier to ensure you’re sharing your complete medical record with every provider you see, you can compile your record using an app, create a document on your computer, or create a paper file. Choosing one of your health care providers to act as your medical home can also be helpful. In most cases, that will be your primary care provider. You’ll need to let your provider know what other doctors you see and have those providers share your records and test results with your medical home. This can help ensure your care is coordinated, and your medical records are consolidated.