Most of us rely on our doctors to keep track of what we might call the technical elements of maintaining our health. After all, it is the physicians who understand and act on the x-rays, MRIs, mammograms, PAP smears, and batteries of blood tests that write our medical history from birth to death.
So why should the recordkeeping be your responsibility?
Because medical treatment based on lack of information or misinformation could kill you.
- In an emergency, you could be taken to an unknown hospital or treated by a doctor who is completely unfamiliar with you and your medical conditions. If you are out of town, you may be far away from family members who have knowledge of your history and medications.
- As modern medicine becomes increasingly specialized, you probably have a handful of specialist physicians in addition to your family doctor or general practitioner – too many doctors with too little time. You cannot count on these busy doctors to share information automatically or consistently.
- Even the physicians you see regularly are suffering from information overload, in addition to patient overload. Unlike the family doctor making house calls in old movies, today’s doctors are often members of large practices that see hundreds of patients each week. So you can’t expect immediate recall of your condition, or even that notes and files are accurate and up to date.
- If you move or change jobs and health insurance companies, you and your family may need a whole new medical care team. If your medical records are not portable and immediately accessible, your care could be delayed or compromised.
- In the unfortunate case of an accident where you or a family member is injured – for example, in a motor vehicle crash, as a result of a defective drug or medical device, or because of the malpractice of a medical professional – the completeness and accuracy of your medical records could be your strongest tool for seeking justice.
Compiling your medical history takes patience and persistence. Here’s how to get started.
The most productive first step you can take in building a comprehensive medical file is to begin asking for copies of medical records and tests whenever you see a doctor. If you seek medical advice for an illness or injury, ask for copies of orders for tests and drug prescriptions. Also ask for a copy of the doctor’s notes related to your symptoms and possible diagnoses. Federal law gives you the right to obtain copies of these kinds of notes, as well as lab reports and test results.
Even if you are having a regular annual checkup and routine blood tests, get a copy of the resulting notes and test reports. Then, if you should be injured or become ill, these prove valuable diagnostic tools, allowing physicians to compare your well-patient profile with new symptoms and conditions.
If you have not been collecting medical records, you will want to try to obtain copies of past exams, tests, and procedures from the medical professionals that have provided them. Generally, only the patient – or the parent or guardian of a minor patient – is entitled to these records. If you are a caregiver, sometimes you can access records with the written permission of your patient.
Here are some helpful hints for requesting past medical records.
- You should contact hospitals and medical facilities directly, in writing for records of care provided in their facilities. But for diagnostic tests such as labs, scans, and x-rays, request them from the physician who ordered them. Most labs will not provide these kinds of results directly to you.
- State laws vary as to the length of time doctors and hospitals are required to retain your records. For example, in many states adult medical records are kept for six years or more, and children’s records are kept from three to ten years beyond age 18 or 21.
- Most medical professionals and institutions will provide a form for you to complete when you are requesting your records. Generally, this form will require such details as your complete name, address and phone, birth date, Social Security number, and dates of tests or services.
- Many providers will charge a fee for providing the records you have requested. These fees vary, but state laws require them to be “reasonable.” It is not difficult to understand that medical practices and institutions want to be compensated for the time it takes for someone to locate your records, and for copies and postage.
- Each state has laws that spell out the time frame within which your record request must be met. Sometimes you can review your records right away in a physician’s office, but you could wait as long as 60 days to get copies.
- Usually, medical records must be kept for ten years after a medical practice has been sold or a doctor is deceased. But as a practical matter, you may find it difficult and time consuming to identify appropriate contacts and find where records are located.
Your privacy rights regarding medical information are protected, in part, by the Health Insurance Portability and Accountability Act (HIPPA).
While you yourself have the right to access your own medical records, there are some limited federal regulations in place regarding how to do that, and to protect your privacy. In your transactions with the medical community, you may have encountered references to the Health Insurance Portability and Accountability Act. HIPPA was passed by the US Congress in 1996 to address security and privacy of health care data, and portability and renewability of health insurance.
HIPPA rules do not guarantee you access to all of your medical information. You can be denied access to information that is the result of psychotherapy or other mental health treatment, or if a provider determines that, as a result of access to your records, you could harm yourself or others.
Neither does HIPPA provide an absolute guarantee to privacy of your medical information. Your physician does not need your permission –written or otherwise – to share information related to your treatment or payment for treatment.
(For a more detailed introduction to HIPPA and your privacy rights related to health care records, see Medical Privacy FAQs compiled by the Privacy Rights Clearinghouse.)
Collecting your medical records is not enough. The next steps are understanding what they mean, and then correcting any errors.
Without a medical degree, you cannot be expected to know all of the medical terms in your records or the meaning of your test results. If you have questions, you should contact your doctor and make sure you understand the implications of the medical information he or she has provided.
If you don’t already know, make sure you are clear about the basic elements of your own health profile, such as:
You may find that, in the medical records you have obtained, some of the information is inaccurate or out of date. A file may not contain a warning about your drug allergy, or it may misstate the dosage of your blood pressure medication. Lab tests critical to a diagnosis could be missing.
It is your responsibility to maintain accurate information about your health and to keep your medical records up to date. If you don’t take this responsibility, you are risking your health . . . and your life.
If you or a family member has been injured by a defective medical device or pharmaceutical, or because of the negligence of a health care professional, the attorneys at Searcy Denney Scarola Barnhart & Shipley have more than 45 years experience in these areas of practice. For a free initial consultation, please fill out our Contact Form or call us at 800-780-8607.