Obtaining and Maintaining Your Medical Records Is Important to Your Health

Challenges to Managing Medical Records

Many patients I see in multiple healthcare settings are overwhelmed and confused about how to access their medical records. Patients must request, obtain and maintain copies of their own medical records to assure the accuracy and currency of their information, identify potential errors and mistakes, and track, manage and participate in their own health care (Reports, C. (2018, February 12). Keeping track of medical records is key to protecting your health. Retrieved March 14, 2018, from Consumer Reports in The Washington Post).

Our healthcare system is extremely complex, rushed, fragmented, and difficult to access.  Physicians and healthcare providers have incredible time pressures placed upon them to see patients and document their care in clinics, physician offices, hospitals, home health agencies, assisted living facilities, nursing homes, and hospice facilities.  Patients and families also have a difficult time understanding acronyms, abbreviations and medical jargon and have issues with medical literacy.  Medical errors are now the third leading cause of death and it is imperative that patients obtain and maintain their own medical records (James, J.T. (2013) A New Evidence-based Estimate of Patient Harms Associated with Hospital Care.  Journal of Patient Safety.  September, Volume 9, Issue 3, p. 122-128).

Requesting Copies of Your Paper or Electronic Medical Records

Patients may obtain paper copies or elect to have electronic access to copies of their medical records.  Electronic health records (EHR) may require you to log in to a secure online computer system using a patient portal.  “You have the right to receive copies of your health information from your doctor and from other providers such as physical therapists and social workers.  If your health care provider keeps your records electronically, you have a right to receive them in either electronic or paper form.”   (Accessing Your Health Information, retrieved 3-11-2018, 1516).

A patient or family member must complete a “Release of information” form for each healthcare facility, where care was delivered, which may include date of birth, social security information, e-mail address and physical address.  An agency may require a driver’s license or other form of identification when submitting these requests or when picking up documents.  Many healthcare facilities are unable to share patient health records between facilities due to privacy and confidentiality laws governing the protection of patient information.    Some patients do not feel comfortable using an electronic patient portal to access their electronic medical records and prefer paper copies.  In some cases, no one will respond to telephone requests and it becomes necessary to physically go to the facility and request your records.  When requesting a paper copy of your medical records, realize that it may take the organization 1 to 2 week to provide these records to you and they may charge a fee for processing your request.

On the request for medical records, you must specify the date of service, the type of medical records you want such as physician progress notes, operative reports, hospital discharge summaries, lab results, radiology reports (CT or MRI scans, etc.), medication administrations, physical therapy notes, occupational therapy notes, chaplain or case manager consults, and other information.

Maintaining Your Medical Records at Home

It is a good idea to store your  paper records and healthcare billing records in a 3 ring binder of appropriate thickness to contain all of your records.  It is very helpful to store your healthcare billing records alongside your medical records to make it easier for you to access in case you need to dispute or appeal your billing to a specific healthcare agency.  Medical records you may want to store include healthcare provider visits, hospital visits, current health information, medical history, medication prescription receipts, insurance claims and payments, advance directives, MOST forms, living wills and power of attorney documents (Organizing Your Medical Records at Home, retrieved 3-11-2018).

It is helpful to place your records in your binder in reverse chronological order with your most recent records and receipts on the top or in front of your binder.   Some healthcare providers will give you CDs for electronic access to your medical records.  Store these in a sleeve or sleeves in your binder.

Lastly, for easy access and portability, print your current medications, with dosages, times and frequencies on one side of a 3×5 card and on the other side of the card, print a list of your current health problems or diseases so that this information can be shared readily with your healthcare provider or clinic for planned and unplanned visits.  Also, include the names and phone numbers of your emergency contact person and the name of your Healthcare Power of attorney   Place this card in your wallet or purse.  Update these lists periodically.

In summary, keeping track of your medical records is key to protecting your health.  Keeping a binder at home of your medical records and receipts in a readily accessible place will make it easier to access this information readily.

 

 

 

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Karen Sanders, MSN, RN, AHN-BC, HWNC-BC

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