your medical records

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"Begin by asking your currentphysician and any previous physiciansthat you can contact for a copy of yourmedical records."

Organizing Your InformationThink of a medical portfolio as your health résumé with supporting documentation. If you go to a new primary care physician or specialist, presentation of clearly organized data will greatly facilitate your health care. You will know that accurate and potentially important information is in your file for future use. However, as with any résumé, be concise in what you present. Dropping a tome of medical records on a new doctor’s desk may not bring you gratitude. You can maintain copies of all your records at home, but present to the doctor a brief summary and test results or other reports from recent years that you think will be helpful. Additional information always can be supplied later from your home file, if necessary.

“Begin by asking your current physician and any previous physicians that you can contact for a copy of your medical records,” Lipman, of the New York Medical College, advises. “If your records are too voluminous to copy—or the handwriting too difficult to decipher—ask for a reasonably detailed typewritten summary. Don’t back down if your physician balks at releasing your records. Most states grant individuals the legal right to their medical records, although some laws allow the physician to refuse if disclosure would be psychologically harmful to the patient.”

When you have gathered your records, here are some suggestions for how to organize the information.

Overview. Prepare a dated one- or two-page summary listing your name, address, and telephone number; names and telephone numbers of medical professionals who have cared for you most recently (primary physician and specialists, if any); highlights of your medical status, including any significant medical conditions and current medications and dosages (Don’t guess! Look them up on the prescription bottles.); any adverse reactions to medications in the past; allergies; information on vitamin, mineral, or herbal supplements you take; all surgeries and their approximate dates. Do this in outline or bullet form for quick reading. Your doctor still may require you to fill out a medical history form for his or her purposes, but even so, preparing your own summary ahead of time will make the task much easier.

Blood test results, urinalysis reports, and other medical test results or reports. Information should be arranged in reverse chronological order (most recent first). This includes EKGs, reports from CT scans, magnetic resonance images (MRIs), ultrasounds, or X-rays. (In addition to the written reports on X-ray findings, keep the actual X-ray films also, but you should not provide them with your portfolio unless they are relevant.) If you have had a series of tests of the same type done, group the similar types of data together and label them, for example, “pulmonary function tests”, “bone-densities”, and “cardiovascular monitoring tests.” Organizing the results in this way will make it easier to track changes over time.

Immunization history. This includes data on vaccinations and booster shots, such as for tetanus. Although this information is particularly important for children (schools and camps require evidence of all necessary immunizations before admission), it is also important for adults to be aware of their immunization history. A recent example involved measles outbreaks on college campuses. Most people receive an MMR (measles/mumps/rubella) vaccination in childhood that creates immunity to these diseases. However, when measles broke out on several campuses nationwide, the colleges, to prevent future outbreaks, began requiring that everyone enrolled in a degree program—even part-time adult students—produce evidence of MMR vaccination or take a blood test to show that they had a sufficient antibody titer to be immune to measles.

Family medical history. Incidence in your family tree of major illnesses such as cardiovascular disease, cancer, mental illness, or diabetes may be helpful to your physician.

Keeping your portfolio up todate becomes easy when youhave done the basic work ofacquiring your previous records.

ConclusionYour physician’s job will be easier and your treatment more effective if you take the time to assemble your medical history. Keeping your portfolio up to date becomes easy when you have done the basic work of acquiring your previous records. Maintaining the overview document on your computer will allow easy updating of the medications you take and other data that may change.

The preparation of a health portfolio is a deceptively simple yet powerful way to assume your part of the responsibility for monitoring your health

Hugs,Theresa