Personal Medical Records

Like most people, you probably have a file of important papers — everything from the warranty for the new vacuum to records of your cats’ rabies shots. But you may not have a stash of the most important documents of all: Your medical records. Why? Because your doctor has them — a necessity, to be sure, but one that isn’t going to do you much good if you need your records in an emergency.

One solution that’s becoming more common is for patients to acquire and keep on file a copy of their family’s medical records.

“You should keep a record of each family member’s medical history at your fingertips, in the home,” says Michael Fleming, MD, former president of the American Academy of Family Physicians (AAFP). “It’s also a good idea to take your records with you when you travel.”

Having your medical records on hand is important for a number of reasons. If you change physicians, or your physician retires, you’ll be able to show your records to your new doctor at your first visit. Your records are also extremely beneficial if you’re taken to a hospital’s emergency room, or when you’re out of town and need to see a physician who obviously knows nothing about your medical history.

“In an emergency, saving time can mean the difference between life and death,” says Fleming. “Having your medical records with you when you enter the ER gives the ER physicians vital information they need.”

Starting your own home medical record

To begin compiling a home medical record, contact your doctor’s office or the medical records staff at every facility where your family members have received treatment. In addition to your primary care physician or child’s pediatrician, including eye doctors, dentists, and any other specialists you have seen. Ask for an “authorization for the release of information” form. Complete the form and return it to the facility as directed. While most facilities charge a fee for copies, be aware that legally this fee can include only the cost of copying (including supplies and labor) and postage if you request the copy to be mailed. If you decide you’d prefer an explanation or summary of your records instead, you can be charged for the cost of preparing one.

Gathering all medical records is just the first step. A medical record that doesn’t provide a snapshot of your current health status isn’t that helpful. Make a point of keeping your medical records up to date, and be sure to include new prescriptions or recent diagnoses.

“A medical record should be a living, breathing document,” says Fleming, “not something that collects dust on your shelf. It should be a diary of your health condition that you update whenever your health status changes.”

Maintain your record by writing down in a notebook what your doctor tells you each time you visit. These notes can be anything from general medical advice to new prescriptions or specific steps you need to take to comply with recommended treatment. This way, you won’t have to wonder if you’re forgetting a piece of advice.

Use a notebook or your computer to store medical information

While you can use a number of formats for a home medical record, one of the most convenient is a three-ring binder or wire-bound notebook with pockets for storing loose documents, such as insurance papers and test results. This notebook should have a divider for each member of your family. This way, all the information is easy to find in one file. Keep the notebook in a specific location in your home, and make sure every family member knows where it is.

“Having separate notebooks for each family member is not as practical and efficient,” says Fleming. “That is particularly true in an emergency when you need to grab the notebook quickly. Having to look for the right one will waste precious time.”

In addition to (or instead of) a notebook, you can maintain your medical information on your computer. There are numerous personal medical record (PMR) software programs that allow you to fill in and update data as needed, or you can create your own medical record using a word processing or spreadsheet program.

Print out the record and take it with you when you travel or go to a new physician or health-care facility. You can also save it to a disc or send it as an e-mail attachment, but be sure to bring your printout as well in case the physician or health-care facility isn’t able to open your file.

More portable electronic health record formats have been developed in the past few years, such as software that allows patients to access their personal health records using an iPod or iPad.

Now available to health-care providers is the Continuity of Care Record (CCR), developed jointly by the AAFP, the Massachusetts Medical Society, the American Medical Association, the American Academy of Pediatrics, the American Health Care Association, the Health Information Management and Systems Society, and the ASTM International (American Society for Testing and Materials), among others. The CCR provides a standard system to create health information documents and send them electronically from one health-care provider to another.

Keep your record secure

Be sure to protect the privacy of your home medical record. If you have a lockbox, safe, or other secure devices in your home, consider using it to store the notebook, binder, or disc (and all printouts).
If you maintain your records on a computer, make sure there are adequate safeguards to protect the information. Back up your information on an external hard drive, and keep an updated printout of your record in case your computer crashes or the file is accidentally erased. It’s also a good idea to e-mail an encrypted copy of your record to a friend or family member for safekeeping.

Information you’ll want to collect

Each person’s section of the notebook or electronic file should include the following information:

• Name, birth date, and social security number
• Names and phone numbers of persons to contact in case of emergency
• Contact information for your personal physicians, dentists, and other specialists
• Health insurance information
• Summary of your health conditions
• Current medications and dosages
• Allergies to foods and drugs
• Most recent physical examination results
• Important test results
• Immunization records
• Vision and dental records
• Opinions of specialists
• Notes or doctor’s advice on your condition
• Correspondence between you and your health-care providers
• Permission forms for release of information about operations and other medical procedures
• Living wills and advance directives
• Organ donor authorizations
• A list and dates of significant past illnesses and surgeries
• A family history including hereditary conditions

Whenever you visit your doctor, update the above information. If you go to the hospital, get copies of reports, discharge summaries, and significant test results. Adding your family’s medical records to your files can be a lifesaver because the next time you need the result of an important test, you’ll know just where to look.

References

My PHR.com. Maintaining a Personal Health Record

My PHR.com. What is a Health Record?

Academy of American Family Practice (AAFP), The Continuity of Care RecordPortable, Easily Exchanged, Personal Information. AAFP CHIT. Continuity of Care Record (CCR).

Medical Records Institute. Continuity of Care Record (CCR) The Concept Paper of the CCR, Version 3.

AAFP’s Center for Health Information Technology. Unofficial FAQs About the ASTM CCR Standard.

Source: HealthDay: www.healthday.com