For a Complete Medical History, Compile Your Own Health Records but be Cautious about Storing Them Online
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Privacy Rights Clearinghouse
Updated: April 15, 2008
Like most people, you've probably moved many times during your life. Settling in to any new community usually means establishing a relationship with a new doctor, dentist or other health care provider. Over time, it's easy to forget when you were treated, by whom - even for what. Even if you've stayed in one place, it's still likely you've received medical care from various providers over time.
There is no one place you can go to get your complete medical history. Each healthcare provider you see keeps his or her own files detailing your visits and treatment. The same is true for hospital stays, physical therapy, laboratories, dentists, optometrists, chiropractors, pharmacies and so on. Only you are in the position to pull all the records together to compile your complete medical history.
If you don't already keep a personal health record, now is the best time to start. Do not rely on your ability to go back in time to collate a complete medical file. The longer you wait, the more difficulty you may have in obtaining older health records.
Here are just some reasons to order your medical records soon after you are treated:
- Records are not kept indefinitely by healthcare providers. Retention times may vary, depending on where you were treated.
- Paper records can be misfiled, destroyed by fire, damaged by water, or simply lost. Paper records are usually not created in multiple copies. This means the original record may be the only copy that exists.
- Older records may be stored on microfiche and the quality can deteriorate over time.
- Electronic records stored on computers, CDs, DVDs or small storage devices called ìthumb drivesî may also be lost or damaged.
- Like everyone else, physicians retire, sell their practice, merge with other practices, or die.
National standards for health privacy are established by HIPAA (the Health Insurance Portability and Accountability Act) and the Department of Health and Human Services, www.hhs.gov. One of the most important rights included in HIPAA is the right to obtain copies of your medical records. HIPAA also allows you to ask to change inaccurate information in your medical records.
For more on your right to access medical records under HIPAA, see PRC Fact Sheet 8a, HIPAA Basics: Medical Privacy in the Electronic Age, www.privacyrights.org/fs/fs8a-hipaa.htm. See the sample letter for requesting a copy of your medical records, www.privacyrights.org/Letters/medical2.htm
Once you have your medical records in hand, you can start to compile your own medical history. Your personal medical file may be as simple as a folder with paper copies of all records you have accumulated from various care providers. You may also want to include your own records about diet or exercise routines.
If you want to add a bit of technology to your recordkeeping, there are many products on the market to help organize and maintain your personal health records. For example, you can purchase software that allows you to create a medical history in a word processing program. Some programs allow you to import data from other sources.
Internet-based storage sites are also springing up. These services allow you to store your medical information, import data from other sources, and share your personal data with providers of your choice. Another storage medium is the medical flash drive, which allows you to store medical data on a small device you carry with you. Producers of flash drives say in an emergency, an ambulance driver can access your data by plugging it into a computer and can even add notes about your treatment on route to the hospital.
A word of caution:
Here are some tips for creating your personal medical history:
- Exercise your HIPAA rights by ordering copies of your medical records as soon after your visit as possible.
- If you have extensive records with any one provider, request a summary of records rather than the entire file. Providers may charge a ìreasonableî fee for preparing the summary based on the work involved. Agree on costs beforehand.
- Maintain your own medical journal. Record dates you visited your doctor, conversations, medications (dose and how often taken), immunizations, test results, and referrals.
- Compile medical history files for your children, particularly records of immunizations that may later be needed when transferring to a new school.
- Talk to older family members about developing a family ìtreeî of health issues that may affect you or later generations. To aid in developing your family medical history, the Department of Health and Human Services has posted forms you can either print or download. https://familyhistory.hhs.gov If you are concerned about putting medical information online, you may be more comfortable with the print format.
- Keep your medical records in a safe, secure place just as you would your other important papers such wills, passports, and financial records.
- Let trusted family members know where to find your medical records, at least those records that may someday figure into the family member's health care.
For a step-by-step guide to creating your personal health record, visit the American Health Information Management Association web site www.myphr.com/your_record/guide.asp
See also the U.S. Food and Drug Administration's PHR form, ìMy Medicine Record, ìat, www.fda.gov/cder/consumerinfo/my_medicine_record.htm . It can be used to keep track of your prescription medicines, over-the-counter medicines, and dietary supplements.
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