PFS001 Making the Most of Your Health Care Visit The American College of Obstetricians and Gynecologists Women’s Health Care Physicians patient education FactSheet PFS001: Making the Most of Your Health Care Visit JULY 2011 To achieve the best health, you need to be an active member of your health care team. One way to be involved in your health care is to prepare for and actively participate in your visits with your health care provider. This fact sheet outlines steps you can take to get the most from your health care visit. Making the Appointment When you make your appointment, be clear about why you need to see the health care provider: • Do you need an annual checkup with your regular health care provider? • Is your visit about a new problem? Be sure to say whether you need to see the health care provider right away (is your problem urgent?). • Is your visit to see a specialist? With some insurance plans, you need to have a referral from your regular health care provider to see a specialist. Make sure you have this referral handy so that you can give it to the specialist. If you are seeing a new health care provider, find out whether he or she accepts your insurance plan. Bring your insurance card with you to the visit. Before Your Visit It is a good idea to prepare for your health care appointment. Doing a few things beforehand helps ensure you will get the most out of your visit. List Your Questions Make a list of any questions or concerns you have. Identify your main problem. Put this problem first so you can bring it up right away. Then list other problems or concerns that you want to discuss. Main problem: __________________________________________________________________________________________________ Other problems: _________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Write Down Your Signs and Symptoms Think about your signs and symptoms. Be able to describe them—what they feel like, when they started, what makes them better. This information helps your health care provider better understand your problem: • Signs are things that you can show to the health care provider, such as a rash, swelling, or redness. • Symptoms are things that you feel and that you describe to the health care provider, such as pain, dizziness, or itching. Signs and symptoms: ____________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ List Your Medications Keep a list of the drugs you take. Include prescribed drugs; over-the-counter drugs, such as pain medicine; vitamin supplements; and herbal medicines. List why you take each drug. Note how much of the drug you take and how often you take it. Update this list at least once a year or whenever you start or stop taking a drug. Medications: ___________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Give a Complete Health History You will be asked about your past health history at your appointment. Your health care provider may give you a form to fill out. If you do not understand the questions, the office staff can help you. Instead of filling out a form, office staff may ask you to provide these details over the phone. You may want to prepare a written health history—a record of your general health—for this and future health care visits. This history is sometimes called a health journal or personal health record. Include information about the following: • Illnesses and injuries • Hospitalizations • Surgical procedures • Drugs (ones you take now as well as ones you have taken in the past) • Allergies, including bad reactions to drugs and foods • Personal information — Exercise habits and diet (including alcohol use) — Factors such as stress at work or events such as getting married or moving that can have a major effect on your life — Harmful health behaviors such as smoking and drug use • Immunizations • Family history of disease (include aunts, uncles, cousins, and grandparents as well as parents, brothers and sisters, and children) Bring Your Past Medical Records If you are visiting a new health care provider, bring any past medical records, X-rays, or test results you have with you. You will need the names and addresses of your past health care providers. Your past health care providers usually can send your health record to the new health care provider. A fee may be charged for this service. You may want to take your record with you if you move. Think About Bringing a Support Person Think about whether you want to bring a friend or relative with you. This person can act as your advocate—someone who knows you and who has your best interests in mind. This person may help you remember something during or after the visit. Make sure you are comfortable sharing information with this person. If you need to bring your young children, also bring someone to take care of them while you are with your health care provider. If English is not your first language, or if you are hearing impaired, you may need an interpreter. Ask the office staff whether they can find an interpreter who is experienced in medical terms. Be sure to give them enough notice. Friends or family members may not make the best interpreters. They may not understand medical terms. Also, you may be discussing sensitive issues with your health care provider that you want to be kept private. Make sure you are comfortable with the interpreter you have chosen. During Your Visit You have a right to ask questions of anyone who is involved in your health care. Speak up if you have questions or concerns. Feel free to ask anything about the health care process. The Physical Examination Your health care provider should make your physical examination as comfortable as possible. Tell your health care provider if something bothers or frightens you. Be clear about your modesty needs. If for religious or cultural reasons you need to have a female provider, discuss this requirement before your visit or when you make your appointment. It is reasonable to ask for a gown or sheet if a doctor or a nurse asks you to take off all of your clothes. If the gown or sheet is too big or too small, let your doctor or nurse know. Some health care providers may have a chaperone present during the exam. Whenever possible, the chaperone should be a health care professional (such as a nurse or nursing assistant). If you would like a chaperone, and your health care provider does not offer one, ask. You can have a family member present during the exam, or you can ask not to have family members present. Make your wishes known. Doctors, nurses, and other health care professionals should wash their hands, but they can forget. If you do not see your heath care provider wash his or her hands, you might ask, “Have you washed your hands?” Handwashing is the most important way your health care provider can prevent the spread of infections. Talking With Your Health Care Provider If you have questions, ask them. Use your list to be sure you cover all of your questions. If the health care provider asks you questions, answer them as best you can. Be honest. Make sure you understand everything your health care provider says. Ask for simple, clear explanations. Ask him or her to draw a picture if you think that might help. Take careful notes. If you have a friend or relative with you, ask that person to take notes so that you can listen more closely to what is being said. If you are given a diagnosis and need further care, ask about your options if they have not been discussed. You should understand the different treatments that are available. When you know all the options, you are more likely to make a good decision. You may want to ask the following questions: • What might have caused this condition? • What are the treatment choices? • What are the benefits and risks of each treatment? • How might the treatment affect my life? • Why is it important that I follow a certain treatment plan? What might happen if I do not get treated? If you need a test, procedure, or surgery, the following are good questions to ask: • Why is it being done? • What does it involve? What do I need to do to get ready? • What should I expect? What are the side effects? • How will I find out the results? • How long will it take to recover? If a medication is prescribed, it is important to know the following information: • The brand and generic (common) names • Instructions for taking the drug — When you should take it and in what relationship to food (with food or on an empty stomach) — Whether you should avoid alcohol — How much you should take — For how long • The side effects that may occur and what you should do about them (also ask your health care provider whether the drug is safe to take with any other drugs you are already taking) At the end of your appointment, repeat what you have learned to the heath care provider. This recap will give your health care provider a chance to correct any misunderstandings. If you need more time to talk about something, tell your health care provider, or see if you can schedule another appointment to continue your talk. After Your Visit If you have received a diagnosis of a certain medical condition, learn as much about it as you can. The more you know about your condition, the more likely you will understand what your health care provider recommends. Make sure you have all the necessary information before deciding on what procedures to have or what medications to take. The Internet and your public library offer lots of health information. Be sure, however, that when using the Internet, you use only reputable web sites. Some sites have misleading information or information that has not been carefully reviewed. Make sure the resources you use are reputable. Web sites sponsored by nonprofit organizations (“.org”) or government agencies (“.gov”) are most likely to be free of bias. Make sure the information is current. Listed are some good web sites to visit: • (The American College of Obstetricians and Gynecologists) • (The U.S. Department of Health and Human Services) • (The American Cancer Society) Contact your health care provider if • you are confused about something • you have other questions or concerns • you start to feel worse or your medicine does not seem to be helping • you have had a test or procedure and have not received the results. Do not assume that “no news is good news.” Some health care providers now use e-mail to communicate with their patients. Ask your health care provider if he or she is available by e-mail. Sometimes, the nurse or other staff members in the office may be able to answer some of your questions by e-mail. If you are not comfortable with the diagnosis or recommended treatment, you can get what is called a “second opinion” about your health problem and its treatment from another health care provider. Getting another opinion can help you make an informed decision about your care. Finally... The relationship between a health care provider and a patient is an important one. As a patient, you should play an active role in this relationship. To get the best care, be prepared for your health care visit. Do not be afraid to ask questions or speak up if you are concerned about something. If you need treatment, know the risks and benefits. PFS001: Designed as an aid to patients, this document sets forth current information and opinions related to women’s health. The information does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice. Variations, taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice, may be appropriate. Copyright July 2011 by the American College of Obstetricians and Gynecologists. 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