Healthy Dose: Managing Your Own Medical Records

Sept. 3, 2008— -- Two weeks ago I talked about the importance of giving your children a copy of their medical information as you send them off to college. Last week I shared with you my father's Emergency Room story. When faced with a serious heart problem from one of his heart medications, the ER doctor was handicapped because he didn't know my dad was taking the drug digitalis because he didn't carry a complete list of medications with him.

But whether leaving home for the first time, faced with a new diagnosis, or caring for yourself and for your aging parents, keeping a complete set of your medical records and carrying a list of your critical health information can be life-saving.

Today I would like to give you a step-by-step guide to collecting your medical records. The information in your medical records is yours and you are entitled to copies from every doctor you see. Doctors can (and need to) charge for the copies, however they often will not if you are asking for only one or two reports.

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 eventually be destroyed by the people or facilities that own them, according to individual state laws.

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 (such as a mistake in the record).

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 directly responsible for, such as an aging parent, a developmentally delayed sibling or grown child, or a grandchild. 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.

Your Family Doctor

Make sure you ask for the following:

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. 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.

And lastly, make this behavior a habit. Be sure to get the results of every test and procedure as they occur in the future by giving your doctor a self-addressed stamped envelope at each office visit when a test is ordered. This will help remind your doctor of your wish to keep your own copies of records as well.

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 three 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 the information may be critical to future doctors involved in your care, and that you are entitled by law to this information.

There is strength in numbers, and if we all start to ask for what is important to receiving the best possible health care in the future, giving patients copies of their records will become commonplace.

Store all your records in a file folder or three-ring binder. Consider adding divider tabs to separate blood tests, x-ray reports and doctor consultation reports and hospital discharge summaries. For a complete set of helpful forms to include in your medical records, go to www.DrSavard.com and click on Learn how to take charge of your health.

Put your records in an easy-to-locate place such as your kitchen counter or shelf where family or emergency personnel could easily find them. Keeping them handy will also help remind you to take them with you to every doctor appointment, emergency room visit or hospital stay. Showing everyone your vital health information could help your practitioners avoid making mistakes, duplicating unnecessary and costly tests, and not having the information they need to make the most accurate and timely diagnosis.

Have you tried to collect your medical records? I would love to hear your experience. As always, I welcome your questions and comments.

Dr. Marie Savard is an ABC News medical contributor. To learn more about Savard's health management system, download free forms and a sample letter to your doctor, visit http://www.drsavard.com and click on "Learn how to take charge of YOUR health."