Healthy Dose: Managing Your Own Medical Records

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. When was your last flu, pneumonia or tetanus, diphtheria and pertussis vaccine?

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.

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 and nothing else. Otherwise, you may get (and be charged for) the whole file, which will be redundant.

Laboratory or Hospital Radiology Department

In the event that your family doctor does not have laboratory results, such as Pap tests, biopsies, blood work, radiologists' x-ray reports, mammograms or bone density scans, you can try contacting the lab or hospital radiology department.

Complementary Care Clinicians

Include important information from all of the complementary care clinicians you may see, including nutritionists, acupuncturists, physical therapists, and chiropractors. Keeping track of vitamins, herbs and other supplements you may have been given is especially important.

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 on my Web site (www.DrSavard.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 scribbled doctor progress notes instead of the typed reports and summaries.

I also suggest that you include a check to cover the cost of copying your records; $10.00 to $20.00 is usually enough. Regardless of whether 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.

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