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Medical History: Using the Past to Support the Present

The Worth of Recording your Medical Past
Medical Records

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As a direct support professional, part of your job is to ensure that the people you support are able to manage their health care needs. One of the best ways to do this is by understanding their medical histories. When you understand and make a record of someone’s medical history, you can work with the person’s health care providers to treat health conditions in the most appropriate ways.

Why is a medical history record important?

Keeping track of and writing down their medical history can be especially important for those with developmental disabilities.

  • People with developmental disabilities often see several doctors and take many medications. By keeping their medical history records up-to-date, individuals can help each of their doctors know the different treatments they are receiving, which can help avoid dangerous medication interactions.
  • Some people with developmental disabilities may have trouble communicating verbally. A written medical history record can provide health care professionals with quick and easy access to the information needed to provide proper treatment, especially in an emergency.

How can a medical history record help me to provide support?

As a direct support professional, an individual’s medical history can help you to:

  • Know which medications an individualtakes and assist with self-administration of medications.
  • Be aware of a person’s allergies.
  • Provide proper first aid – for example, you would respond differently to a bee sting depending on whether the person who was stung is allergic to bees.
  • Respond to an emergency – by knowing an individual’s medical history and keeping the information readily available, you can quickly share needed information with emergency personnel.
  • Respond to new signs or symptoms – by understanding someone’s past conditions, you can tell if their symptoms are new or recurring concerns.

What can I do?

The information that makes up a complete medical history may come from many different sources (see box). By gathering these pieces of information in one folder, you can make sure that the medical history record is easily accessible to you, the person you support, and the person’s health care providers. You can:

  • Assist the people you support to gather all the information from their medical history into one document or folder.
  • Encourage those with serious allergies or health conditions to wear a medical alert bracelet.

FACT FOCUS: Medical History and the IPP

As a member of someone’s planning team, it is important to consult that person’s medical history record as you are assisting with his or her Individual Program Plan (IPP). A current health history record and physician’s report should be used to identify and address the individual’s health care needs during the planning process. A completed IPP sometimes includes a healthcare plan that describes:

  • Goals, objectives, and plans for health care needs.
  • Specific responsibilities of the direct support professional and others involved in the person’s life.
  • A way to evaluate the plan’s success in supporting the individual to achieve or maintain the best possible health.

Severe Allergic Reactions: Learn about Anaphylaxis

Many people have allergies that cause uncomfortable symptoms, such as itchy eyes, a runny nose, or a rash. While these types of allergies are irritating, they can often be managed without visiting the doctor. However, anaphylaxis is a severe allergic reaction that requires immediate medical attention. As a direct support professional, it is important for you to know how to respond
to this life-threatening condition.

What are the symptoms of anaphylaxis?

Anaphylaxis is characterized by hives, swelling, difficulty breathing or swallowing, rapid heart rate, and dropping blood pressure. In severe cases, a person experiencing anaphylaxis can go into shock, and may die.

The first sign of an anaphylactic reaction may be severe itching of the eyes and face. This can rapidly progress to more serious symptoms, including hives, difficulty breathing, abdominal pain, vomiting, diarrhea, a racing heartbeat, and shock. If not treated, a person having an anaphylactic reaction can die within minutes.

What are some common triggers of anaphylactic allergic reactions?

Food is the most common trigger for an anaphylactic allergic reaction. Common food triggers include:

  • Peanuts and tree-nuts
  • Shellfish, such as shrimp or lobster
  • Dairy products
  • Eggs, especially egg whites
  • Sesame seeds

Other common triggers include:

  • Bee or wasp stings
  • Medications, such as penicillin
  • Latex rubber

What should I do if someone I supportexperiences anaphylaxis?

Individuals who have any history of anaphylaxis, even if the reaction was not severe, should always carry an epinephrine injection kit that is prescribed by their doctor. If someone you support needs an epinephrine injection kit, read the individual’s healthcare plan and talk to their physician. Be aware that there may be specific licensing or other regulatory requirements regarding medications and the provision of specific medical supports depending upon the type of residential service model where you work.

Encourage people with severe allergies to wear a medical alert bracelet. This will help emergency personnel and others know what to do if a person develops anaphylaxis.

Anaphylactic reactions often become more severe with repeated exposure to the trigger. This means that someone who had a mild reaction to something in the past is likely to have a more severe reaction in the future. As a direct support professional, it is vital for you to know what triggers could lead to an allergic reaction, and to help individuals maintain an environment free from these triggers.

Last updated on Wed, 06/30/2010 - 16:55