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Medical Records 101

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Your medical records are a vital part of your health care and are also important to your finances. It is advisable that there is at least one place which has a complete, accurate and up-to-date copy of your medical records.  

  • If you are in a health care system that uses electronic records, all your records will be in one place, accessible by each of your doctors. To be sure they are accurate, you can ask for access to the system. More and more health care facilities offer patients access to their records online. If you have such access, check your record periodically, say once a month.
  • If you are not in such a health care system, and/or use medical care outside the system, like it or not, it is your job to make sure that your medical record is accurate and complete.  Alternatives to consider include:
    • Keep a copy of your records yourself. If you prefer, there are online sites that can help such as Microsoft's Health Vault offsite link and/or
    • Ask each specialist and other doctor or health care professional you see to send copies of all medical entries, tests and test results to a doctor you pick - either a specialist  that you see regularly or your primary care doctor. This should include any doctors you see while traveling. Instead of relying on a doctor remembering to send the information:
      • Remind each doctor at each session to send the notes to your doctor of choice.
      • Ask how long it will take for the notes to be forwarded. 
      • Note the date on your calendar. 
      • Check with the office of your primary physician on that date to see if the records were received. 
      • If the records were not received, follow up with the office staff of the dotor who is supposed to send the information.

You can assure the accuracy of your medical record by taking the following steps:

  • Obtain and review a copy at least once a year, say at tax time or other trigger date with your doctor or at least a member of his or her staff. 
  • Ask about anything that you don't understand.
  • Ask that anything that is wrong be corrected in the record. If the doctor or nurse balks at making a change, remind him or her that you have a right under the federal law known as HIPAA to make corrections to your medical record. If they refuse to make the change, you have the right to provide a written statement and ask that it be included with your medical records. To learn more about HIPAA, click here
  • (If you have kept a Health Journal about your health, you can compare the dates, symptoms and procedures against the doctor's records. If you haven't been keeping a Health Journal, this is a good time to start. In addition to other advantages, a journal saves you time, particularly when getting ready to see a new doctor.)

If you work:

  • Be sure that your medical records contain information about how your condition affects your daily living and ability to work. (Tell the doctor at every appointment, and ask that the information be included in your medical record). While this may not seem important now, it could become very important if you want to stop work at some point and apply for government or private disability benefits because of your medical condition. (For example, see applying for Social Security Disability Income or applying for a disability income benefit.)
  • Your record should also include any emotional states you experience such as depression or anxiety. This information will also be important if you eventually apply for any government or private disability benefits.

Confidentiality of your medical records

  • You have a right to privacy about your medical record. In addition to the state laws, the federal law known as HIPAA provides privacy except  in certain circumstances. The provisions of the law have been adopted by just about all doctors and medical facilities.
  • The American Medical Association (AMA) confirms the existence of a basic right of patients to privacy of their medical information and records. The AMA also states that patients' privacy should be honored unless waived by the patient.
  • General practice is for doctors and medical facilities to give you a copy of their confidentiality policy. Many ask that you sign a document agreeing to the policy. If you have questions, or disagree with what you read, speak with the doctor's office manager or with the doctor -- or a supervisor in the facility.
  • For the steps you can take to protect the confidentiality of your medical record, click here. 

For additional information, see:

NOTE: 

  • If you have an Advance Directive known as a Health Care Power of Attorney,your proxy stands in for you when it comes to making medical decisions and should be able to see your medical records. Rather than rely on "should," it is advisable to include a specific provision in your health care power of attorney saying you give your proxy authority to see and copy your medical record to the same extent you could, without limitation.  
  • If you will be filing a claim to be considered to be disabled, it would be helpful to let your doctor know ahead of time you may be applying for something that will require disclosure of your medical records. For example, that you are thinking about applying for Social Security Disability. We're not suggesting the doctor change your records to make them misleading. Instead, if she knows what is important to you, your records can be written in such a way that they will bolster your case by making notes that would otherwise not be in your file or be said in a manner that is helpful. 
  • If one of your doctors announces that he or she is retiring, or a facility in which you had x-rays or MRIs taken is about to close, ask for a copy of all your films in case they become relevant in the future.
  • You can manage health care information with a mobile app such as AARP's AARP Rx.  For example, if you take a picture of your prescription bottles with your smart phone, the app will automatically record the drug name, dosage, pharmacy and refill schedule. You don't have to type anything.Next time you see a doctor, you have a handy list of your meds to show him or her.  You can also track informatoin such as blood pressure. You can download the free app at aarp.org/rxapp or by sending the text "aarprx" to 742864.

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