All About The Personal Health Record

Personal health record and health report shown on tablet by e-health system.

Personal Health Record, in short, PHR is a health record where the health data and information related to the care of the patient is maintained by the patient. It offers a complete and accurate summery of an individual’s medical history that can be accessible online. The health data includes the patient-reported outcome data, lab results, etc.

The PHR is a tool that you can use to collect, track and share past and current information about your health or the health of someone whom you care. The PHR provide more insight into your personal medical history even though routine procedures do need to be repeated. Generally, the PHR contains a diverse range of data that includes:

  • Family history
  • Chronic diseases
  • Allergies
  • Adverse drug reactions
  • Illnesses and hospitalizations
  • Laboratory test results
  • Imaging reports such as X-rays
  • Medications and dosing
  • Surgeries and other procedures
  • Prescription record
  • Vaccination
  • Observations of daily living i.e. ODLs

The PHR is both paper-based and computerised systems. But the latest form of PHR implies an electronic application used to collect and store the health data and that can easily be accessible from anywhere, anytime over the internet.

There are two ways of preparing PHR. A patient may enter it directly, by putting the information into the fields. The second way is electronic health record that updates the PHR automatically. The Personal Health Records plays a vital role and thus needs to be prepared carefully. Here are some important points about a PHR:

  • Access complete health information before you fill it into your PHR
  • The information you enter into the PHR should be reliable, complete and accurate
  • It is vital to have control over how your health information is used, accessed and disclosed
  • PHR is not a legal medical record of any provider rather it is a record prepared by the person that can assist the medical practitioner in diagnosing and deciding the treatment

One more thing is the PHR is different from medical record. Medical record contains the information about your health compiled and maintained by the healthcare providers. Whereas, the PHR is the information about your health and that is compiled and maintained by you on your own.

To prepare quality PHR you need to take an active role in monitoring your health. For this you can refer the book, ‘The Personal Health Record’ that can assist you in getting started, addressing current PHR trends and processes.

Reports Common To Most Of The PHR

  • Identification Sheet – This is a form originated at the time of admission or registration. The form lists your name, address, contact number, insurance, policy number, etc.
  • Problem List – This is a list of significant illnesses and operations
  • Medical Record – The list includes medicines prescribed to you.
  • History And Physical – This document describes the major illness or surgeries you have had. It also includes the family history of disease, your health habits, current medications, etc. The sheet also states what the physician found while examining you.
  • Progress Notes – These are the notes prepared by the doctors, therapists, nurses, social workers caring for you with respect to your treatment. The notes also include the observations and plans for continued treatment.
  • Consultation – This includes the opinion of the physician other than your primary care physician. Or it is as good as a second opinion of another physician on a particular disease.
  • Physician’s Orders – This includes the orders made by your physician to other members of the healthcare team with regards to your medication, diet, tests, treatments, etc.
  • X-Ray Reports and Imaging – This describes the findings of ultrasounds, scans, x-rays and mammograms.
  • Lab Reports – The report describes the results of tests conducted on body fluids such as urinalysis, throat culture, cholesterol level, complete blood count, etc.
  • Immunization Record – This includes the list of immunizations given for different diseases like measles, mumps, rubella, polio, flu, etc.
  • Consent And Authorization Forms – This includes the copies of consents for admission, treatment, surgery and release of information.

Along with the above reports, the PHR also includes some additional reports which are common to hospital stays or surgery, such as:

  • Operative Report – This is a document that describes the surgery performed and the name of surgeons and assistants.
  • Pathology Report – The report describes the tissues removed during the operations and diagnosis based on the examination of the removed tissues.
  • Discharge Summary – This includes the summary of hospital stay, the reason for admission, the significant findings from tests, procedures performed, the therapies suggested and provided, your response to the treatment, your condition at the time of discharge, etc. It also includes the instructions given to you for medication, activity, diet and follow-up care.

The Personal Health Record may contain all or some of the above reports and documents. Depending on what illness you are suffering from or any injury you experienced, you can use the services of the intensive care unit, emergency room, home health nurse, etc.

The PHR is very helpful. The information it contains, the report attached and medications listed are all important. It is useful for monitoring your health and the coordinate the care you receive. This also ensures the quality healthcare facility for you. Your PHR may be useful for further research in the world of medication. It can be used as legal document in cases where evidence of care is necessary.

PHR Useful For Healthcare Providers

The healthcare department find PHR as the most important document to review information about you. The information used to monitor and improve the quality of care you receive. It is also used as a legal document in case where evidence of care is necessary. Hospitals can share the information of PHR with family members without your authorization if you are unable to provide your consent.

PHR Used By Insurance Companies

PHR stands very important document for insurance companies. After your health information is collected is used to bill for the services you receive. The billing process is now-a-days transmitted electronically to those paying your bills. Generally, people have medical insurance, accident claims, etc. The insurance companies prefer Personal Health Records along with other important doucments for settling the claims.

PHR plays a crucial role and more active role in your healthcare. The PHR plays vital role in dicision-making when it comes to treatment options, cost of treatments, potential health conditions, management of chronic conditions, preventive actions, healthy lifestyle choices, monitoring the accuracy and security of your health information. It offers a wide range of benefits to you in getting best treatment, settling insurance claims and maintaining good health.