Overview
Where are your medical records?
Probably with your doctor, as they should be. Your doctor needs your
health records to track your care and provide the best treatment.
But it's also a good idea to have your own copy of these records. This is
known as a personal health record, or PHR.
You'll need your health
records if you change doctors, move, get sick when you're away from home, or
end up in an emergency room. If any of these things happen and you have your
records, you may get treatment more quickly and it will be safer.
You'll want to keep a summary of your PHR with you at all times and keep
detailed information at home.
What to keep with you
If you have a summary of
your health records with you, you'll get the best possible care if you get sick
or have an accident. Keep personal information and current and past health
information.
Personal information includes:
- Identification, such as a driver's license.
- Who to
call in an emergency.
- The name and phone number of your primary
doctor.
- Your insurance card.
- Your organ donor card, if you
have one.
Current health information includes:
- Information that is needed in an emergency,
such as whether you have a
pacemaker or a
stent, or have hearing or vision
problems.
- A list of your long-term (chronic) health problems, such
as
arthritis,
asthma,
diabetes, or
high blood pressure.
- A list of the
medicines you are taking. Include prescription and
over-the-counter medicines, dietary and herbal
supplements, and vitamins and minerals. For each medicine, give the name of the
doctor who prescribed it, why you are taking it, how much you take, and any
special instructions.
- A list of your allergies, including
drug or
food allergies.
Your medical history also is important. Be sure you carry
a list of:
- Major health problems you've had in the past,
such as
pneumonia or
broken bones, or problems with alcohol or
drugs.
- Major health problems in your family, such as heart disease,
stroke, cancer, or diabetes.
- A history of childbirth, if you're a woman. This includes how
many children you've had and any
miscarriages,
cesarean sections, or abortions you've had.
This seems like a lot of information to carry, but it can
be one page if you write short lists rather than sentences. Keep this in your
wallet or purse.
You also can keep this information on a thumb or
flash drive, which is a small storage device for information stored on a
computer.
What to keep at home
Having medical records for
each member of your family can help you make better health decisions. Records
to keep include:
- All the information noted above.
- An
immunization record with dates of childhood
immunizations. Also include boosters, flu shots, and other vaccines you've
received.
- Any health screening results, such as those for
blood pressure,
cholesterol, vision, and hearing.
- Any
cancer screenings, such as
Pap tests,
mammograms,
colonoscopy, and
PSA (prostate-specific antigen)
tests.
- Records of any major surgeries or times you were in the
hospital.
- Records of your hearing, vision, and dental visits.
- A list of medicines you've used in the past.
If possible include:
- A copy of your
advance directive, including a
living will and
power of attorney.
- Your pharmacy name and
phone number.
- The poison control phone number.
- Records
of insurance claims and payments.
- Written notes from your doctors
or doctor visits.
- Anything else about your health that you think
is important.
How to get started and store your medical information
Get a copy of your health records from your family doctor and anywhere
you've received health care. To get started, call your family doctor and ask
for your records, or wait until your next visit. Ask your doctor if he or she
can help you make a personal health record. Your family doctor also may be able
to help you find other places where you may have medical records, such as at a
hospital. Your records may be kept in paper or electronic form.
You may need to sign an "authorization for the release of information"
form. You may need to complete this form for every facility that you request
records from.
You also may be asked to pay for copies of your
records and the time it takes to make copies. You also may be charged for
mailing fees. Always ask how long it will take to receive your copies.
After you have your information, you need to organize it. Here are some
ideas:
- Use a 3-ring binder or wire-bound notebook
with dividers for each member of the family. If you get a notebook with
pockets, you can keep test results and other health papers in these pockets.
- Create a file on your computer with your information. Create
the file in any software program you feel comfortable using.
- Use
software that creates a personal health record.
- Store your health
records on an Internet site. Your health plan or hospital may have one.
The American Health Information Management Association
(AHIMA) sponsors an Internet site where you can search for paper-based,
software-based, and Internet-based personal health records. Go to
www.myphr.com/resources/phr_search.asp.
