How to Have Your Own Complete Medical Record

Let’s face it. There is, almost without a doubt, no file cabinet or computer file in the universe that tells the story of your body’s health over your lifetime. Who knows what Long List Medical Records 11.3.15shots you got as a kid, and in what sequence? Or how your lab work has changed over time? Who has a copy of the analysis of every medical test you’ve had, every biopsy your dermatologist has taken, the x-ray that was done when you broke your leg when you were in college or the positive Pap smear you had in your 20’s? What was your last PSA (prostate specific antigen test), and when? Who knows exactly what immunizations you’ve had as an adult, and when?

Most likely, all that data, and more, is in the storage facilities of dozens of different doctors, some of whom have sold their practices or died.  Yet that data could be useful and meaningful to you and your physicians should a health issue occur or recur.

Start today with creating your own file folder or computer file of your health data, and your family’s, too, if you’re a parent or caregiver:

  • Call your physicians and ask for copies of your most recent lab work and any other data and reports, such as mammograma, Pap smears, MRIa, biopsy or x-ray reports, bleeding times if you’re on anticoagulants (blood thinners), etc. If these are fairly recent and in your current chart, there should be no charge for these. You actually have a right to see them and to have them; they are yours. (Remember, it’s body, your data, and healthcare providers are consultants to YOU).
  • Start a running record of all health-related visits. Note when you went, who you saw, why you went, and what you learned about your health. Note any recommended follow-up, change in medications or other pertinent information.
  • Create a page for adult immunizations and record the date and type. This is especially important now that they’re recommending some vaccinations from childhood be updated in adulthood. You also need to make sure your tetanus, pertussis, shingles (if you’re 60+), pneumonia, flu, hepatitis and other vaccinations are in line with current recommendations. And if you travel out of the country, you’ll be glad you’ve recorded what you’ve gotten and when.
  • From here to eternity, ask every physician you see for a copy of any analysis they get or do related to your body, right then. For example, I recently had a tiny biopsy of something on my skin. Afterward, I asked for what is called the “pathology report,” the pathologist’s analysis of what was there. Sure, I can remember what the office staff told me when they called. But in a few years, who knows what the value of the precise language might be? And of course, I could forget! It’s also important to read these summaries carefully. You can learn a great deal. And sometimes you may note something that the office staff or the physician didn’t see. Getting a phone call that “you’re fine” from the doctor’s office isn’t the same as reading the analysis for yourself.
  • If you wear glasses or contacts, keep your prescriptions. Make an extra copy and carry them with you when you travel, just in case you need them.
  • If you have a major procedure or surgery, ask for the surgical report. It goes into detail about what was done and what was seen. You may not understand all of the language, but having it is smart, especially if you end up with a related problem or if you see another surgeon who could benefit from the more detailed information.

Keeping this “My Body” medical file current over time will save you time and money and will most likely improve the quality of care you receive. You may avoid having to take a repeat test. The data may help guide a healthcare provider to more effectively diagnose or prescribe for you. And you will surely be saved a thousand phone calls to all sorts of offices and hospital medical records departments in case someone wants to see one of these reports!

Yes, more physicians are maintaining electronic medical records. But even so, nothing is better than having your own personal file of all your reports and data.

Should you move away, getting the records from your physicians won’t be necessary. You’ll have all the essential data in your file.

Thinking it’s just too much trouble? It’s not.  All it involves is asking for a few xerox copies when you see a healthcare provider and making a few notes now and then.

Be sure to keep the file in a safe place because the information is personal. I guarantee you’ll be glad you have your own medical record, ready when you need it.

About Barbara Bronson Gray, RN, MN

I'm an experienced healthcare and science editor and journalist. But most of all, I'm a registered nurse with many years of experience working in hospitals. I've learned what patients and families need first hand. But I've also worked to improve hospitals and educate people about their health. I'm committed to helping people take charge of their health care and get what they need from a complex and often discouraging healthcare system.
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