fundamentals
Handling Medical Records
Introduction
People may not have ready access to their medical record kept electronically or as paper files in the doctor’s office. But in the United States, although the doctor or institution owns the physical file itself, people are considered to "own" their medical information, including the right to view it, have copies of it, and request that any errors be corrected. Other people are generally not entitled to view someone's medical records without explicit permission except as needed to provide health care to the person (for example, hospital staff caring for a patient, or a specialist consulted by the doctor, can access a person's medical record without a separate consent for each use). People also may give written permission for others to view their records, which may be important to allow a family member to participate in care decisions. Also, the courts can require submission of copies or summaries of the records, but only in certain specific legal situations that most people do not experience. When people request their medical record for themselves or to be sent to other health care professionals, they sign a written form authorizing release of the information. Then a staff member at the doctor’s office or hospital usually releases a copy of the record or creates a summary of all or part of the record. Generally, people need only the most useful medical information and not a complete record, which may contain a lot of information that is not useful to them. (See also Introduction to Making the Most of Health Care .) To make sure they always have what they need, people should maintain a personal medical record of the most significant information. They should not rely on memory. Immunization records, which are traditionally kept for children, should be kept current throughout life. People should write or ask someone to write their medication regimen on one sheet of paper to keep with their medical record. They should also keep a copy of their medication regimen with them at all times in case they need emergency medical care. This information can be updated as the regimen changes. Copies of laboratory results should be included with the medical record for future reference. Keeping a list of significant test results (for example, x-rays, electrocardiograms, echocardiograms, colonoscopies) can be quite useful. People may also want to keep a diary of their symptoms with their medical record. Computer software, internet programs, and cell phone apps are available to record most medical information, or a file box or binder may be used. Additionally, many doctors' offices provide secure, online portals that people can access to view their laboratory results, prescription information, and summaries of office visits. Significant or chronic medical problems Current medication regimen Other treatments Allergic reactions to medications Hospitalizations, including operations (dates, location, attending doctor’s name, and diagnoses) Laboratory and other test results Family medical history Immunizations, including dates Visits to any doctor’s office (dates, reason, test results, diagnosis, and recommendations) Copies of advanced directives Billing, insurance claim, and payment information Keeping a copy of their medical record helps people participate in their health care. For example, it helps them better explain a problem to a health care professional. Confidentiality laws and ethical principles protect the privacy of communication between people and their doctor. These laws also protect the contents of the medical record that is maintained by a doctor or hospital. One such law is the Confidentiality and HIPAA (HIPAA). HIPAA states that disclosing a person’s medical information normally requires the person’s written consent. In the doctor’s waiting room, people are asked to sign a form confirming that they are aware of HIPAA and their privacy rights. The form also states how their medical information can be used and shared. HIPAA allows medical information to be shared in certain specified cases. For example, it can be shared To coordinate and facilitate a person’s treatment (especially important when different practitioners and health care facilities are involved) To enable doctors, other practitioners, and hospitals to be paid for health care Thus, information needed to authorize payment may be shared with health insurance providers, who may require medical information as a condition of payment for a claim. Sharing this information also requires the person’s consent, which is usually obtained before health care is provided. A person’s medical information cannot be shared with the person’s employer or marketeers unless the person gives written consent. Increasingly, health care practitioners are recording and storing medical records electronically. This practice has the potential to enable different practitioners who care for the same person to share information about the person more easily and with fewer errors. 