How to Make Sure Your Specialist has the Right Medical Records

If you’ve been referred to a specialist, such as a cardiologist, gastroenterologist, orthopedist, or oncologist, it’s important that specialist has access to your complete, up-to-date medical records to ensure that he or she is aware of any health conditions you’re living with, medications you take, and past surgeries and diagnoses. Having that information can help lower the risk of misdiagnosis, duplicate testing, and inappropriate treatment.

Making your medical records available, however, can be more complicated than you think. Some primary care physicians act as their patients’ medical homes and gather both their own records and records from other physicians who treat their patients. Of course, if your primary care physician isn’t aware that you’re seeing another physician or undergoing diagnostic tests or imaging, he or she can’t include those records, so be sure to keep your primary care physician up to date on all the care you receive.

In addition, not all primary care physicians follow this model, so it may be up to you to gather your records and provide them to the specialist. There are apps and online tools that you can use to store your records, or you can request printed records from your physicians and put together a paper version of the information. A health advisor can be another resource to help you build a secure, up-to-date electronic medical record.

How to build your medical record and what to include

To gather the information you need to share with your specialist, first make a list of all the doctors you currently see and have seen in the past, as well as facilities where your doctors have sent you for tests and imaging. If you’ve been hospitalized, you should also request the treatment and discharge notes from the hospital.

In most cases, you need to request your medical records in writing or through the practice or facility’s patient portal and there may be a fee for getting a copy of the records. If you’re submitting a written request, you need to include:

• Your name
• Address
• Phone number
• The last four digits of your Social Security Number
• Date of birth
• A few sentences about what medical records you’re requesting
• Who to release the records to (you can have then sent directly to the specialist or collect and deliver them yourself)
• Your signature

In addition to these medical records, you should provide your specialist with:

• Your family health history, for example whether your parents and siblings have been diagnosed with cancer or had a heart attack, and the details of their diagnosis and treatment
• A list of medications you take and the dosages, including over-the-counter medications, vitamins, and supplements
• Any side effects you’ve experienced from medications
• An outline of any chronic or serious conditions you’ve been diagnosed with, the treatments you underwent, and any complications from the treatments, even though some of this information may be included in the records you gather from your current and past physicians
• The results from any diagnostic testing or imaging you had that led to your referral to the specialist