Your_Medical

WHY YOU SHOULD GET COPIES OF YOUR MEDICAL RECORDS AND REVIEW THEM

[Edited by a patient with a chronic disease. Last update 21 April 2005]

What medical records should one have on hand?

During or after each appointment, the physician will make a report of his findings. It will generally include a description of the patient's current symptoms and the physician's conclusions about those symptoms--that is, what was told the physician, what the physician has concluded, what the physician told the patient, and his recommendations.

Sometimes this report will contain only data from the test (such as the objective results of a blood or lung-function test).
Sometimes it will be a narrative report from the physician reading the test (the report of the radiologist reading a CT or MRI scan, for example).Surgical and Pathological Reports.

For each biopsy or surgical procedure there will be a pathology report, and for each surgery there will be an operative report. These narrative reports are key records with critical and fundamental information about your diagnosis.

Reasons for obtaining reports - You need copies of these reports for several reasons.

Other professionals involved in your care will ask to see some or all of your previous and current medical information.

A physician may recommend that the patient see another physician or other medical professional who is not in your physician's practice group or hospital.

The patient may decide on their own to seek an additional opinion or to evaluate a different type of treatment option.

Even though a patient has confidence in their current physician and don't anticipate the need to seek other professional opinions, the patient needs to obtain copies of the reports made by the patient’s physicians about their condition in case of future emergencies or changes in health care.

Right to have copies of medical records (U.S.)

Patient's in the U.S. have a right to see and have copies of your medical records under United States federal law, and, in certain situations, also to request the health provider to correct them.

Some foreign countries or provinces may have more stringent or additional requirements.

How to obtain medical records (in the U.S.)

The wise patient determines how to do that before an emergency makes the missing records vital to their welfare.

In the U.S. healthcare providers can advice the patient about its process for reviewing and copying records.

Providers should also advise on the amount of time the provider may take to provide the copies and the cost of copying.

At the patient’s request, the health provider may prepare summaries of the reports as part of your registration at your first visit.

If the patient does not receive copies of medical reports and information on the first appointment, the reports should be subsequently requested.

Collecting past medical records – For people with a serious condition, time can be important.

Making formal requests and following up on them can be very time-consuming and burdensome.

Reports should be requested routinely at the start of every appointment or test procedure.

The patient needs to have past reports readily available. The process can take days or weeks, so one can't count on having their records available during an emergency unless the reports have been acquired earlier and routinely.

Past records must be requested from each separate institution and each medical professional. They are likely to have different request form and processes.

For persons who have multiple medical professionals involved in their care, it’s necessary to have those records on hand for immediate access.

Records may have been misplaced, misfiled or lost so relocating the originals or having acquired copies before they are needed is important.

Routinely ask for reports at the time of the examination or other office appointments.

Developing good personal relationships with one’s physicians, their administrative staffs and the those who administrator tests goes a long way to helping to get what is needed in the least expensive and most convenient way.

Physicians are often willing to give patient’s copies of their reports of examination or the patient’s general tests (such as blood tests) at each appointment, if the patient requests them before the end of their appointment and explain why the patient wants them.

For special tests, such as MRIs, CT scans, X-rays and the like, the person administering the test rather than the physician who orders it tends to be the "gatekeeper" for copies.

The patient must request a copy of special tests before the test is taken. The test-taker can then order two copies and supply the patient their copy at the same time as the physician gets his. The patient will likely get the copy free or at nominal cost if requested in advance.

Originals of imaging results can usually be signed out temporarily from the radiology department where the x-ray was done if needed for consultation with other physicians.

Imaging tests (x-ray/ct scan/mri/ultrasound, etc.) may be stored as either a film original, or as a digital file. Images on film are sometimes not kept past five years so it may be important to get a baseline image duplicate film for future comparisons.

Reviewing Medical Records – Reasons why one should review the reports their physician writes and the patient’s lab test results and imaging records.

Reading the reports helps one to better understand what the physician is intending to communicate and suggests questions that one should ask the physician, whether immediately or during the next appointment.

A physician may have misinterpreted something the patient said or omitted something the patient believe is important. This won't known that this has happened unless the patient reviews the reports.

A review can improve communications between the physician and patient even though it may produce no new insights that change the patient’s view of their illness or treatment.

Physicians often provides a lot of information about an unfamiliar subject very quickly and often speaks in jargon or "medical shorthand" that can be easily misunderstood.

The patient can try to make sense out of the reports by diligently asking physicians any questions raised during the review

Physicians are busy and can make mistakes. They are not intimately aware of r symptoms, r life-needs, or r concerns. They focus their attention on the most significant current elements of r case. Something that seems minor to the physician may be significant to and should be brought to the physician’s attention during the appointment.

Giving bad news is not easy, so physicians may communicate it in an indirect way.

The patient should never be worried about taking the physician’s time, concerned about asking "dumb" questions, or intimidated about following-up; this is, after all, r illness and r life.