The Most Important Medical Document You're Not Keeping
How a simple Home Medical Record helps patients stay afloat.
A Simple Problem
In just a few weeks, I’ll complete the first and hardest year of residency: internship. If forced to distill the experience into a single image or phrase, it would be this…
And let me tell you… I wish I could say I was John Wayne…
Though during this year, as I splashed around, oftentimes aimless and wild-eyed, I noticed something odd: most of the patients around me were splashing too. Not in the same pond, but in one of their own. Here was my takeaway: hospitals have a way of disorienting people—but those without a firm grasp of their medical baseline are far more likely to get swept away by the current.
Medical baseline?
Yes… as in the “ins and outs” of your day-to-day operations. Things like the following:
Medications you take
Why you take them
The name of your primary care physician
What your primary care physician manages
Other physicians you may see in the outpatient setting (cardiology, nephrology…)
This discrepancy stems partly from low health literacy, but also from poor communication skills and the complexity of the healthcare system itself. As I’ve discussed in detail in previous articles, a core role of a doctor is to teach their patient and communicate their disease/treatment effectively. However, this does not imply absence of a patient’s responsibility to their own care. That responsibility is twofold: first, to care well for themselves—eat right, sleep well, be a good person, etc—and second, to understand the basics of their medical encounters. Though we cannot understand everything, we ought to understand what we can.
Every time a doctor encounters a patient, a note must be created documenting its content. I propose the same is true in reverse: every time a patient encounters the healthcare system, they ought to create a note. The Home Medical Record, or HMR, is the best way to do this. Treat it like a checkbook to balance your medications; or a journal to organize your hospital experiences. It is a medical ledger created by you that works for you.
Side note: You may say, “I have access to my doctor’s notes and lab results now. Why do I need to waste time to keep my own records?
For a couple reasons: first, your doctor’s notes aren’t written for you… they’re written for other physicians. This means you likely won’t understand the content of the notes. Second, writing/organizing is an active form of learning. Therefore, you will comprehend and retain information better… and be better for it. Third, and most importantly, because your health is your responsibility.
A Simple Solution
Physicians and other healthcare staff often use the acronym SOAP when discussing patients: Subjective, Objective, Assessment, and Plan. This is conveyed in their notes. The HMR, I propose, should look similar but not the same. Since SOAP is likely a foreign concept to patients, a familiar structure should be used instead. I call that structure the “5W’s + To-Dos.” If you say it out loud it kind of rhymes, so it’ll stick in your head better.
What are the 5W’s and To-dos?
Glad you asked. We’re going back to kindergarten for “Who, What, Where, When, Why… and To-do.” This is the structure of the HMR.
Who: Whenever you encounter the medical system, it’s imperative to know by whom you were treated. Names of people and their roles in your care are documented here.
What: The content of your visit. This will likely be the longest portion of the record.
Where: Document the hospital system, the setting, and the city.
When: The date or dates of your encounter
Why: This is the purpose of your visit. Did you need new labs? Workman’s comp? A mammogram? Or because you simply, “felt sick?”
To-do: These are any action items following your encounter.
Some HMR Examples
Example #1: A person who was admitted to the hospital…
Who
I was a patient of Dr. J and his team.
What
I was admitted to the hospital for a bad infection called sepsis which was due to pneumonia. The infection was in my blood, which they called bacteremia, and I was treated with IV antibiotics. They switched me to oral antibiotics before discharge.
Where
This took place at the Hospitals R’ Us Medical Emporium.
When
May 32nd-37th of 2025
Why
I first went to the emergency room because I was coughing for a few days and began coughing up gunk. I felt terrible and was shaky. So I went to the ED and the doctor in the ED - I don’t remember his name - said my lungs sounded bad. He also said I had a really bad fever. I got a cat scan of my chest which showed pneumonia, so I was admitted to Dr. J’s team.
To-Do
Per my discharge paperwork, I’m meant to take this oral antibiotic (called Levaquin) for 2 weeks and call my PCP’s office to schedule an appointment to follow-up my hospital visit.
See? Simple and to the point. Here’s another example in a different style.
Example #2: A person and their annual checkup…
— “I saw my primary care doctor, Dr. Bartholomew Fitzsimmons with Hospitals R’ Us, for an annual checkup on February 29th at his office in Smithville. He manages my high blood pressure with Losartan 25mg daily and my pre-diabetes with just diet and exercise. During this visit we discussed the lab work he ordered for me a week ago. My A1c, the number that correlates to blood sugar, was down to 5.6 with the lifestyle changes I made. We’re both happy with the number and I will continue what I’m doing. My labs otherwise look okay (thyroid, cholesterol, and electrolytes). We also talked about my blood pressure logs at home and they are mostly at our goal (110-120/70-80). Overall he was happy with how I was doing… as am I! I will continue the course and I’ll call him if I need anything. Follow-up in a year.” —
Time for Action
Give it a shot!
The next time you visit your doctor, go to the hospital, or even call in a medication refill, log it in your personal HMR. A notebook or digital doc will do just fine. Use the structure we covered: the 5W’s and To-Do’s.
Over time, with consistency and endurance of effort, you’ll become something rare: a formidable steward of your own health.
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Great advice, Doc!