Want The Full Picture?How to Collect Your Own Medical Records.
Medical Record Collection 101
I know that the idea of figuring out where the paperwork is and trying to collect it--much less understand it--sounds overwhelming, but in the end, you’ll be glad you made the effort. The last thing you need when you’re sick and frightened is to have to think straight enough to remember where your old mammograms might be, or the names of the medications you’re taking. Far better to take the time and trouble to get your medical affairs in order right away and keep them up to date from now on. Consider it a kind of insurance that is guaranteed to pay out. Plus, if you don’t collect your records yourself, they could be destroyed within two to seven years by the people or facilities that own them.
Your Medical Records Belong to You
People often ask me if they are entitled to their medical records. The answer is, unequivocally, yes. While the original documents are owned variously by health care practitioners, hospitals, and laboratories, you are legally and ethically entitled to copies of the information in your medical record. In fact, federal privacy laws include a section that emphasizes the fact that patients are not only entitled to copies of their medical records, they can even suggest changes or corrections if and when it is appropriate. At the state level, there are some laws spelling out patients’ rights to their health information and how much patients can be charged; however, there is no state that has a law saying you can‘t have your records.
Note: You should also get copies of the records of your minor children and anyone else you are responsible for, such as an aging parent, a develop-mentally-delayed sibling, a grandchild, or unrelated child you have taken into your home. In these latter cases, you’ll need legal power of attorney in order to access the person’s medical records.
Locating Your Medical Records
Your records can be in a variety of locations, including doctors’ offices, hospitals, and laboratories.
Let’s first take a look at each possibility.
1. Your Family Doctor. Make sure you ask for the following:
Progress notes, including a running record of your height, weight, and blood pressure.
Typed summaries dictated by specialists you’ve seen, such as cardiologists, gynecologists, or urologists.
Discharge summaries from hospital stays and emergency room treatment.
Results of all blood work and urinalysis.
Pathology reports (Pap tests, biopsies, etc.).
Radiologists’ reports, such as chest x-rays, mammograms, and bone density scans. You may also want to get a copy of the actual x-ray pictures along with the typed reports. This is especially important for women who move and need to have mammograms read and compared at another facility.
Results of heart testing (EKG, cardiac stress test, cardiac echo).
Results of screening and diagnostic tests, such as allergy testing and colonoscopy.
Immunization history. If your doctor doesn’t have this, blood tests can determine which antibodies you have, should the need arise.
2. Specialists. If your family doctor has not received these consultation reports from the specialists, you’ll need to contact the specialists directly. Also, if you see a specialist regularly, such as a cardiologist, make a habit of getting your results on an ongoing basis, just as you do when you visit your family doctor or gynecologist.
3. Hospital Medical Record Department. In the event your family doctor does not have hospital discharge summaries, contact the medical record department at the hospital and specifically request the summary. Otherwise, you may get (and be charged for) the whole file, which will be redundant.
4. Laboratory or Hospital Radiology Department. In the event that your family doctor does not have laboratory results, such as Pap tests, biopsies, or blood work, or radiologists’ x-ray reports, mammograms, or bone density scans, you can try contacting the lab or hospital radiology department.
5. Complementary Care Clinicians. Contact all of the complementary care clinicians you may see, including nutritionists, acupuncturists, physical therapists, and chiropractors.
Obtaining Your Medical Records
When gathering your existing records, work in reverse chronological order. What I mean is, don’t let yourself be stymied by the potentially impossible quest for long-lost records. Start with your next office visit, and request your results and summaries. Give your doctor a self-addressed, stamped envelope and a sticky note with the current date, the records you want sent to you, your name in legible block letters, your date of birth, and your signature. He can then put the sticky note as a flag on your chart to remind him to follow through. Make sure he understands that your motive for requesting the records is simply to have a set for yourself, so you can work with him to reduce the risk of medical mistakes.
Next, let your other doctors and practitioners know what you are trying to accomplish by writing a brief, courteous letter to each person or facility that might have what you need. I have a sample letter at my Web site resources section (www.AskDrMarie.com) that you can download for free to help get you started.
In all correspondence, be sure to give your date of birth and the medical record number (located on all x-ray reports), if you have it. You’ll also need to be specific about which records you want, or you may get a sheaf of useless, scribbled notes along with the typed reports and summaries.
I also suggest that you include a check to cover the cost of copying your records; $10.00-$20.00 is usually enough. Whether or not your doctor accepts the money, she’ll appreciate the offer. Similarly, if you are not having the records faxed to a personal fax machine, I recommend that you include a 9x12, self-addressed, stamped envelope.
And lastly, make this behavior a habit. Be sure to get the results of every test and procedure as they occur in the future.
Follow Up with a Phone Call
But what if you don’t get your records in spite of the pleasant tone of your letter? I recommend that you wait 3 weeks, and then make a follow-up phone call.
If the office staff tells you that it’s not the doctor’s policy to send patients copies of their records, don’t allow yourself to be intimidated. Be polite and persistent. Remind them it is not only your legal right, but the information may be critical to future doctors involved in your care, and that you are entitled—by law--to this information, no matter where you live. There is strength in numbers, and if we all start to ask for what is rightfully ours, giving patients copies of their records will become commonplace.
Carry a Lifesaver with You
Once you’ve gathered your information, make several copies of your personal health information list, and carry one with you at all times. It should include the following information:
A list of medical conditions, such as hypertension, diabetes, osteoporosis, even a heart murmur that requires antibiotics before dental work;
Serious adverse reactions to medication, bee stings, seafood, x-ray dye, etc.;
An up-to-date list of medications, vitamins, and herbal supplements, including
dose and directions;
Significant family medical conditions;
Most recent immunizations for tetanus, flu, and pneumonia; and
Living will information.
My dad now carries an emergency lifesaver with him at all times and has shown it to every doctor, pharmacist, and practitioner that he sees.