Why you need to gather and organize your medical records
If you’re like most people, you probably see several healthcare providers over the course of the year—your primary care provider and a few specialists like cardiologists, dermatologists, OB/GYNs, mental health specialists, and orthopedists. Then there are visits to urgent care or retail clinics, virtual visits through apps or your health insurer, screening and diagnostics tests, inpatient and outpatient hospital care, pharmacies, and care provided by other health professionals including physical therapists, nutrition specialists, and complementary and alternative medicine providers like acupuncturists and functional medicine specialists. That’s a lot of important data about your health that’s not often gathered in one, centralized medical record.
There are several reasons gathering, reviewing, and organizing your personal medical records is important:
- Complete, accurate records can lower the risk of misdiagnosis, missed follow-up care, and duplicate or inappropriate care because providers and patients have a comprehensive source of information to base their recommendations and decisions on.
- Keeping an updated copy of your medical records can help you understand any health issues you’re living with and manage them more effectively, making you an informed and active partner in your care.
- Having a comprehensive medical record can help providers make better informed decisions when you need emergency care or cannot speak for yourself.
- If you want to seek a second opinion, it’s helpful to be able to share your complete medical records with the consulting doctor.
How to gather your medical records
If your providers use a patient portal, start gathering your records there. Most portals allow you to download providers’ after visit summaries, notes, test results, prescription lists, and other communications. You can also request a copy of your records by writing to your providers. Some providers will make paper copies of your records for a per page fee.
New federal rules enacted in October 2022 should make gathering your medical records more efficient. The rules are part of the 21st Century Cures Act and they give patients full, free, secure access to all of their medical records provided in a timely manner and in a digital format. Because the rules are new, it will take some time for providers and other data holders to comply, but make sure to ask if your provider is able to create and share a digital record with you.
Do you prefer to store your information on a computer or smartphone or are paper records easier for you to use? There are apps that can help you organize your medical records or you can create a document on your computer to centralize the information. Make sure to check the security and privacy of any digital format to protect your personal information.
If you prefer paper records, use a binder or file box to store medical records. To make finding information quick and easy, divide the information into sections, for example, hospital records, imaging results, doctor’s notes, prescriptions, and so on.
What to include in your personal medical record
There are several key pieces of information you’ll want to gather:
- A list of all providers you see: Include the providers’ names, contact information, and their specialty.
- A list of all your medications: If you take medication regularly, list all prescription and over-the-counter medicines and any supplements, including the name of the medication or supplement, the dose, and how often you take it. Also keep a list of any side effects or allergic reactions you experience.
- Your family health history: Include key information about close family (parents, grandparents, siblings) such as diagnoses of serious conditions like cancer, heart attack, or stroke, cause of death, and chronic conditions like diabetes or high cholesterol.
- Your personal health history: List any chronic conditions or serious diagnoses, what treatment you’ve received, and how well controlled the condition is. You should also include information on any surgeries, hospitalizations, or serious accidents or injuries.
- Provider and hospital care summaries and notes
- Test results: This should include blood and urine tests, imaging like X-rays, MRIs, and CT scans, biopsy results, and screening test results like mammograms, PSA tests, DEXA scans, and colonoscopies.
You may also want to keep copies of your insurance information, advance directive or living will, medical power of attorney, and a some medical bills (for example, bills with errors or that are still under review by your insurer).
Gathering and managing your medical records can be a challenge. A health advisor or care navigator can help you gather and organize your medical records and make sure you keep the information up to date.