Get Smart: Health record keeping now can help you later

As your family grows, so will the need to keep good records, especially when it comes to health. You can keep your personal health record in a file in your desk or on a computer disk, whichever works best for you.

Maintaining a personal health record at home is one of the best ways to be sure you have access to information from your health care provider, as well as keep track of your own health. No one person can possibly remember the dates and years that their children had measles or their partner had his first PSA test for prostate screening.

Women tend to be so busy taking care of every one else's health that they sometimes forget about their own. But it's important to take note of when you had your last Pap smear or the last time your blood pressure was taken.

You'll be especially glad you kept things like immunization records. Someday the baby you are now carrying may call home with the news, "I can't go to school unless you bring my immunization records."

Your records: What you should include

Person to notify in case of emergency

Name and contact numbers of family members' doctors, dentists and optometrists, plus pharmacy information

Copy of your health insurance benefits and contact numbers

List of current medications

Immunizations and dates

Allergies

Important events and dates in your personal and family medical histories

Important test results

Eyeglass prescription information

Dental information

Copies of advance directives (your wishes for medical care in the event you are unable to make a decision)

Organ donor authorization

Should you keep copies of your own medical records?

While it may be burdensome and unnecessary to get copies of your medical record every time you visit your provider, you should get copies of:

Surgery reports

Discharge summaries

Significant tests from any hospital visits, such as diagnostic ultrasound or x-ray.

It is especially important to get your records if you had problems with a previous pregnancy. You will want your current provider to see what happened to you and how you were treated.

Your medical record: How to access it

The truth is that your medical record is owned by your doctor or the facility that provides it, though you still have legal access to it. The Internet is helping to open up patients' access to their own records. Meanwhile, state laws vary in the amount of access they give to patients who want copies of their health information. If you run into problems, check with your state's department of health for regulations.

Usually most providers allow patients to have copies. However, typically you will need to make a request in writing, by filling out a standard release of information form or by sending a letter. Also, you may be charged for photocopy costs.

Be sure you know what the facility requires before making the request. It may want information in addition to your full name, address, and dates of service. For example, it may want to know your social security number. If your provider is part of an HMO, you may be asked for your consumer or patient number.

Date last reviewed: October 2002.

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