Model Health Record

A health record example is a one page document which you and your patient carries with them (in your purse) at all times.  In an emergency clinical situation you would pass the one pager to the clinicians.  It saves a lot of form filling and does not rely on anyone’s memory.  Use the following example.

Mary Smith

Severe Rheumatoid Arthritis

Immunosuppressed

Condition List

• Blepharitis – diagnosed 2010
• Total knee replacement of the right leg –June 2013
• Cataract operation, right eye, 28 January 2014
• Vasadepressor-type syncope episode 6 March, 2105
• Sjögren's syndrome as a secondary  - diagnosed July, 2015

Regular Medications

• Tocilizumab,
• Denosmab 60mg subcut injection 6 monthly from July 2014
• Endone 5 mg tablets for flares, as required
• Ezetrol, 10 mg for LDL per day
• Prednisolone 3.5 mg per day
• APO-Tramadol SR 150, 1 per day plus 200 1 per day
• Pantoprazole 20mg per day
• Sterilid eye cream

Bloods as at 7 July 2018

• Rheumatoid factor 464 (less then 16)
• CCP Abs 291 (less than 5)
• Cholesterol Fasting 5.6 (less than 5.5); HDL = 0.9, LDL = 4.1
• ESR 1 (less than 30)
• ANA 320 homogeneous
• CRP 0.4 (0-5)

Allergies, reactions and warnings

Sulphur based drugs (swelling), Tetracycline (rash), Aspirin (if high dose Prednisolone, stomach bleeding), Atorvastatin (pain increase), Rosuvastatin (weakness and pain surge), Lyrica (depressed), Alendronate Sodium (pain increase), Risedronate (ill, jaw pain), Ciclosporin (not compatible) and Protos (not compatible).

End of Life Will - yes

Clinicians

• Rheumatologist: Dr Christopher XXXX
• GP : Dr Craig XXX. 
• Colorectal Surgeon: Dr Chris XXX
• Cardiac Specialist: Dr Raj XXXX
• Knee Surgeon: Dr Peter XX
• Eye Specialist: Dr Ken XXX
• Immunologist: Dr Kate XXX
• ENT: Dr  J XXX

Carer

Christine YYYY + (phone No.)  

A fun and informative video.