For a Complete Medical History, Compile Your
Own Health Records
but be Cautious about Storing Them Online
Privacy Rights Clearinghouse
June 18, 2006
Like most people, you've
probably moved many times during your life. Settling
in to any new community usually means establishing a
relationship with a new doctor, dentist or other health
care provider. Over time, it's easy to forget when you
were treated, by whom — even for what. Even if you've
stayed in one place, it's still likely you've received
medical care from various providers over time.
There is no one place
you can go to get your complete medical history. Each
healthcare provider you see keeps his or her own files
detailing your visits and treatment. The same is true
for hospital stays, physical therapy, laboratories,
dentists, optometrists, chiropractors, pharmacies and
so on. Only you are in the position to pull all the
records together to compile your complete medical history.
If you don't already
keep a personal health record, now is the best time
to start. Do not rely on your ability to go back in
time to collate a complete medical file. The longer
you wait, the more difficulty you may have in obtaining
older health records.
Here are just some reasons
to order your medical records soon after you are treated:
- Records are not
kept indefinitely by healthcare providers. Retention
times may vary, depending on where you were treated.
- Paper records can
be misfiled, destroyed by fire, damaged by water,
or simply lost. Paper records are usually not created
in multiple copies. This means the original record
may be the only copy that exists.
- Older records may
be stored on microfiche and the quality can deteriorate
over time.
- Electronic records
stored on computers, CDs, DVDs or small storage devices
called “thumb drives” may also be lost or damaged.
- Like everyone else,
physicians retire, sell their practice, merge with
other practices, or die.
National standards for
health privacy are established by HIPAA (the Health
Insurance Portability and Accountability Act) and the
Department of Health and Human Services, www.hhs.gov. One of the most important rights
included in HIPAA is the right to obtain copies of your
medical records. HIPAA also allows you to ask to change
inaccurate information in your medical records.
For more on your right
to access medical records under HIPAA, see PRC Fact
Sheet 8a, HIPAA Basics: Medical Privacy in the Electronic
Age, www.privacyrights.org/fs/fs8a-hipaa.htm.
See the sample letter for requesting a copy of your
medical records, www.privacyrights.org/Letters/medical2.htm
Once you have your medical
records in hand, you can start to compile your own medical
history. Your personal medical file may be as simple
as a folder with paper copies of all records you have
accumulated from various care providers. You may also
want to include your own records about diet or exercise
routines.
If you want to add a
bit of technology to your recordkeeping, there are many
products on the market to help organize and maintain
your personal health records. For example, you can purchase
software that allows you to create a medical history
in a word processing program. Some programs allow you
to import data from other sources.
Internet-based storage
sites are also springing up. These services allow you
to store your medical information, import data from
other sources, and share your personal data with providers
of your choice. Another storage medium is the medical
flash drive, which allows you to store medical data
on a small device you carry with you. Producers of flash
drives say in an emergency, an ambulance driver can
access your data by plugging it into a computer and
can even add notes about your treatment on route to
the hospital.
A word of caution:
Commercial products sold
to organize and store your medical data vary from vendor
to vendor. Just like paper records, data stored on your
computer or a distant web site can be lost, stolen,
or damaged. Electronic data -- whether on your computer,
a distant web site, or a data storage device -- is also
vulnerable to unauthorized access. If you consider purchasing
one of these products, be sure to read the fine print,
especially the company's posted privacy policy. When
shopping for technology, encryption is a must.
Here are some tips for
creating your personal medical history:
- Exercise your HIPAA
rights by ordering copies of your medical records
as soon after your visit as possible.
- If you have extensive
records with any one provider, request a summary of
records rather than the entire file. Providers may
charge a “reasonable” fee for preparing the summary
based on the work involved. Agree on costs beforehand.
- Maintain your own
medical journal. Record dates you visited your doctor,
conversations, medications (dose and how often taken),
immunizations, test results, and referrals.
- Compile medical
history files for your children, particularly records
of immunizations that may later be needed when transferring
to a new school.
- Talk to older family
members about developing a family “tree” of health
issues that may affect you or later generations. To
aid in developing your family medical history, the
Department of Health and Human Services has posted
forms you can either print or download. https://familyhistory.hhs.gov
If you are concerned about putting medical information
online, you may be more comfortable with the print
format.
- Keep your medical
records in a safe, secure place just as you would
your other important papers such wills, passports,
and financial records.
- Let trusted family
members know where to find your medical records, at
least those records that may someday figure into the
family member's health care.
- If you consider
keeping your personal health record in electronic
format, carefully read the privacy policy of vendors
that sell such products. Be sure data encryption is
included in any product you purchase.
For a step-by-step guide
to creating your personal health record, visit the American
Health Information Management Association web site www.myphr.com/your_record/guide.asp
