What is written in my medical records?
Have you ever left a doctor’s office or hospital with unanswered questions about your health condition or medical treatment? Given our current health care system,
in which most doctors or medical providers spend only a few minutes with their patients, it is not uncommon for the patients themselves to have little or no information regarding their own healthcare.
While the health care provider may not provide much information directly to the patient, the patient’s medical record often contains important information regarding the patient’s health. When it comes to ensuring you are receiving the best medical care possible, obtaining copies of your medical records is a terrific way to meet this goal.
Why is having a copy of your medical records important?
Most people have more than one doctor involved in their health care. While your primary care physician usually acts as the manager of your health care, often your specialist physicians do not communicate with each other or do not receive important information about your medical history. Lack of communication between your physicians can lead to mistakes and problems. One of the best ways to avoid problems and to ensure that all of your medical providers have the information they need about your medical history is to keep copies of your own medical records and bring them with you to medical appointments. This doesn’t mean you need to carry around stacks and stacks of medical records. However, it is suggested you have your most up-to-date medical records with you at your medical appointments. It is not safe to assume that your specialist physicians, such as cardiologist, orthopedists and endocrinologist, have seen your medical records or have all the information they need regarding your health.
How do you obtain copies of your medical records?
You ask! The simplest way to obtain copies of your medical records is to ask your doctor’s office for copies following each appointment. Even if they are not immediately available, you should request your records or test results be mailed to you as soon as they become available. You will be required to confirm your request for records in writing and sign such request.
The laws in New York State allow a patient to request their own medical records from any medical provider or health facility. For example, the “Patient’s Bill of Rights” allows a patient to review their own hospital medical record without charge and to also obtain a copy of such records for a reasonable fee. The hospital is not permitted to deny you a copy of your medical records just because you cannot afford to pay the charged fee.
Other “qualified persons” can also gain access to medical records and obtain copies if requested. Such “qualified persons” include parents of minor children, attorneys, holders of health care proxies for living people and distributees of a deceased family member.
Did the doctor of hospital give me the records I asked for?
The quick answer is maybe, or maybe not. In the “old” days, medical records were kept in actual medical charts, on real paper, and were stored on shelves. However, those days are gone. You have probably noticed that many doctor’s offices and hospitals have computers, which the doctors, nurses and receptionists use to record everything that occurs during your doctor’s appointment or hospital stay. Many times the record or note of your medical appointment is only available on a computer system and is never printed off and placed in your “paper” medical chart. While computers have aided the medical community in sharing information about patient such as you, often times medical providers don’t know where to look for a patient's medical records. One doctor may only look at the computer records and not the paper medical chart itself, when there could be valuable information found only in the paper chart, and not on the computer, or vice versa.
That is why it is very important that when you request to view or copy your medical records, you also request copies of any computer or electronically stored materials that relate to your health. For example, laboratory test results or radiology reports may only be available by searching a computer database, and not recorded in the paper chart, so you want to make sure to specifically request all records, not just those that are contained within your “paper” medical chart.
“Cheat Sheet” for your health
It seems like everyone today has a Blackberry®, IPhone® or at least a computer they use everyday. Why not create a “cheat sheet” of your medical information for quick use at medical appointments or in case of a medical emergency? It can be as simple as a list of what medications you are currently taking (including dosage and frequency) and the name, address and phone number of all of your current treating physicians. You may also want to include your health insurance plan information and the name and contact information of your heath care proxy, if you have one.
With your “cheat sheet” available, you can have confidence that your medical providers will have basic up-to-date information at each appointment. You can even provide the nurse or doctor with a copy of your “cheat sheet” to save time and ensure accuracy.
