Taking Charge of Your Medical Care

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Fast Facts

A personal medical record combines all of the medical information collected by each facility or doctor involved in your care into a single file that is easily accessible.

  • Personal records should include test results, treatment reports, and notes from each hospital, clinic, or health care provider you have visited.

  • Federal law requires doctors and medical facilities to allow patients to access to their medical records.

  • Hard-copy files of medical information should be kept in a safe deposit box or fireproof home safe, while online files should be password protected and backed up onto a CD, flash drive, or password- protected cloud.

Keeping track of your personal medical information is an important step in managing your care. 

  • Having a compilation of your test results, treatment reports, and the chart notes written at your reports allows you to maintain a comprehensive record of your medical history, especially if you visit more than one doctor.

It is smart to maintain up-to-date personal copies of your own records. This is your personal information, and having this gives you the power to be your own medical advocate. Here are some very good reasons to be proactive and organized about maintaining records for yourself.

If you need a medical record from a certain time and date, you have it filed away and it is always available when you need it.

  • Should you decide to see a new doctor, you can bring your complete medical records and ensure that you have the best care possible. Your comprehensive health records tell a story that is much more easily understood than trying to remember dates and symptoms at your new appointment.

  • If you have had side effects or any complications with surgeries or other procedures, they will be clearly marked in your records. Doctors may also add notes after your visits that you deserve to have copies of.

  • Some time when we go through traumatic illness, (especially as children) we may forget the minute details because we want to put the experiences past us. These records allow our doctors to be fully informed of our medical history without having to relive the experiences.

  • Having all of our medical records in a singular, easily accessible location is an asset to our children. Genetics tend to play a large role in certain medical conditions, and the ability to hand down medical records is priceless. Allowing them the opportunity to recall what treatments worked well could help in their healing processes as well.

  • There is something to be said about the comfort of our own homes, especially in contrast to new doctors’ offices. Having a personal copy of your medical records allows yourself the ability to sit and go over them carefully in the comfort of your own home.

  • Having a personal copy of your medical records is empowering. Being able to read them whenever you choose – without needing to fill out a request form, and then wait for processing – is your right as a patient.

  • Having your own copy can also be a great help with managing insurance claims. The process of keeping track of what is paid and not paid can be simplified when you can look at the policies and your records at the same time. This also applies to legal matters.

  • Further, you may be eligible for new insurance benefits, and being able to match your medical records to such policies can benefit you.

  • If you have had cancer in the past, a recurrence of cancer gives new doctors details. You might have moved and the stress of the diagnosis causes an overwhelming feeling. Having the records, and being able to share them at your own will, makes the situation more contended.

What is considered medical records when a hospital asks?

It depends on the reason and the hospital. The hospital will usually tell you what they are looking for. 

If it is cancer recurrence:

  • It is best to have your diagnosis, cancer type and what stage if there are metastasis.

  • What was the date you were diagnosed and the date of recurrence?

  • Homeopathic treatments

  • Copies of any radiology, diagnostic, blood work and other lab and pathology from any surgery (biopsy, lumpectomy etc.)

  • Complete treatment information, such as chemotherapy drug names, doses, radiation sites and doses of radiation therapy, surgery and hormone therapy - anything that was prescribed for treatment.

  • Treatment Start dates and end dates and if you are still on the therapies

  • Complications, side effects

  • List of medications or procedures used to treat side effects and pain, nausea, other types of care, such as physical therapy and nutritional support.

  • Treating physician and specialist contact information including psychologist, psychiatrist, etc.

  • Hospitalizations

  • Surgeries

Most hospitals provide access to medical records through secured online portals. However, because this is a somewhat new system, not all hospitals have transitioned to ‘being online.’ Should that be the case, know your power and act upon your rights. Formally request a copy of your records from the hospital directly, and they will help you.

In Summary

Remember to organize your personal medical records and keep them secure. Put them in a safe deposit box, or a home safe. Online records should have a password that no one can figure out. It is wise to have one person you can trust to give a copy of the most important medical information to in case of an emergency. Look at the process of compiling your medical records as one of empowerment; you are in charge, and you deserve to have the entirety of your medical history documented and available at your desire or need.

CMN Hospital