• Your Guide to Medical Records

     
     
     
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    Obtaining Medical Records

    You will likely be asked at some point to obtain patient medical records from one physician and provide them to another physician for you or someone you care for. This allows the new medical provider to review the diagnostic and treatment history, preventing duplicate or unnecessary tests and showing the new provider relevant medical information. Furnishing a copy of medical records will also be necessary when seeking a second opinion.

    In the United States, your legal right to view and request your records is governed by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA’s Privacy Rule outlines appropriate sharing of your protected health information (PHI), such as between medical professionals and insurers or with other medical staff or contractors with insurance companies or hospitals. This means that you will be required to authorize that a copy of your records be sent to the new physician who requested them. A good resource for information about medical records and HIPAA is the U.S. Department of Health and Human Services (HHS) website.

    The process for obtaining your records can vary slightly depending on the medical provider, but in general, you can follow these steps to have your records sent to a treating medical professional. These basic steps apply to sharing of both paper and electronic health records (EHRs). Please note that HIPAA does not give you the right to access notes from treatment by a psychotherapist, and the rules for sending those notes to other providers differ.

    To obtain your medical records:

    • Contact the physician’s office or hospital at which you were treated to find out their process for requesting your medical records. In some cases, you will be asked to submit a signed letter. Ask the office about any requirements for the format of the letter. In other cases, the medical center will have a form available to you to fill out. These forms can sometimes be downloaded from the provider’s website and printed.
    • Be sure to indicate on the form or in the letter whether your records should be sent to another provider’s office or if they should be sent to you. Provide detailed, accurate address information for the recipient of the medical records. If you are sending the records to another provider, contact that provider’s office to find out the exact address and who should be listed as the recipient. In addition, you should follow up with the recipient provider to ensure that all pertinent information has been properly sent.
    • Ask the provider from whom you are requesting the medical records about any fees that you will need to pay. By law, providers are allowed to charge you a reasonable fee for copying and sending the medical records (though not for retrieving the records).
    • If you have the medical records delivered to your home or office, before giving those records to your new provider, photocopy the records and keep a copy in your home files for future reference.

     Keeping a Personal Health Record (PHR) at Home

    One step you can take to feel more in control of your health care or that of your child is to maintain a personal health record (PHR). This is simply a term for a record that you maintain on your own, versus a medical record that is maintained at your medical provider’s office. A PHR allows you quick access to your medical information, such as notes, provider contact information, and test results, in case of an emergency or if you need to supply past health information to a new provider.

    You can keep your personal health record in whatever format is easiest for you: as a paper file, using software on your computer, or by using a web-based platform. If you choose to use a web-based platform, be sure to read the privacy practices carefully and be sure you feel comfortable with both the privacy statement and the security of the website.

    Each format has advantages and disadvantages:

    • Paper file. Request a copy of your medical records from your physician (see the guidelines above) and put these records in a binder, file folder, or other container. You may wish to keep this file in a firebox alongside other important papers. Keep notes of any medications you have taken or are taking and when, as well as any allergies to medications. Also note tests you have had performed, any immunizations and allergies, and a list of surgical procedures that includes the diagnosis, date of surgery, and the surgeon’s name and contact information. A paper file gives you complete control over your health information, but you can only access that information if you have the file with you.
    • Software. Choose a computer program that has the features that appeal most to you. Keep notes about your doctor’s visits, diagnostic tests, surgeries and procedures, family history, immunizations, and any allergies. Software may make it easier for you to organize your information. Be sure to create back-up copies of the electronic file, or periodically print out your health information and store it in a secure location, in the event that your computer crashes and the information is lost.
    • Web-based platform. This is the most portable form of personal health record. You can access your information wherever there is an Internet connection. You can also allow your physician to directly access the information. This is still an evolving format. Shop around for the product that works best for you. Some web-based personal health records specialize in certain diseases or conditions, while others are more general. This is the least secure of the three options, as you are transmitting your health information electronically and storing it with a third party. Be sure you feel comfortable with the platform’s privacy policy and security practices.

    Questions to Ask Your Doctor About Medical Records

    • Which medical records do you need from me?
    • Who (hospital social worker, etc.) can help me with requesting my medical records or those of my child?
    • What is the process for having medical records from another provider sent to you?
    • How do I have medical records from treatment with you sent to another provider?