Organizing Your Medical Records [en Español]
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It's a good idea to keep copies of your medical records.
You'll need them if you change doctors, move, get sick when you're away from home, or end up in an emergency room. If any of these things happen and you have your records, you may get treatment more quickly, and it will be safer.
You can write a short summary of this information and keep a copy in your files and in your wallet or purse. You also can keep this information on a portable storage device for computers. Be sure that someone you trust also knows where you keep it.
How do you get started?
To get started, call your family doctor and ask for your records, or wait until your next visit. Ask your doctor if he or she can help you make a personal health record. Your family doctor also may be able to help you find other places where you may have medical records, such as at a hospital.
You'll need to sign a release form. In fact, you may need to sign one at every facility that you request records from.
You also may be asked to pay for copies of your records and the time it takes to make copies. And you also may be charged for mailing fees. Ask how long it will take to receive your copies.
Here's a tip that might save you time and money: be specific about the records you want. Otherwise, the hospital or doctor's office might simply copy every single item in your file—and charge you for all of it. A smaller group of records might be cheaper and also easier to organize.
After you have your information, you need to organize it. Here are some ideas.
Use a notebook or paper filing system
Use a 3-ring binder or wire-bound notebook with dividers for each member of the family. If you get a notebook with pockets, you can keep test results and other health papers in these pockets.
Use your computer
Use any software program you're comfortable with, or get software specifically for personal medical records.
Another option is to store your health records on a secure Internet site. Your health plan or hospital may have one that you can use for free.
The American Health Information Management Association (AHIMA) sponsors an Internet site where you can search for paper-based, software-based, and Internet-based personal health record systems. Go to www.myphr.com.
What records should you have?
Your medical records should include:
- Current health information.
- Your medical history.
- Records of recent insurance claims and payments. Experts advise keeping these for up to 5 years after the service date. But if they're related to your tax returns, keep them for 7 years, along with those tax returns.
- A copy of your advance directive , including a living will and power of attorney .
Current health information
Current health information includes:
- Information that is needed in an emergency, such as whether you have a pacemaker or a stent or have hearing or vision problems.
- A list of your long-term (chronic) health problems, such as arthritis, asthma, diabetes, or high blood pressure.
- A list of the medicines (What is a PDF document?) you are taking. Include prescription and over-the-counter medicines, dietary and herbal supplements, and vitamins and minerals. For each medicine, give the name of the doctor who prescribed it, why you are taking it, how much you take, and any special instructions.
- A list of your allergies, including drug or food allergies.
Your medical history
Keep records of:
- Major health problems you've had in the past, such as pneumonia or broken bones, or problems with alcohol or drugs.
- A history of childbirth, if you're a woman. This includes how many children you've had and any miscarriages, cesarean sections, or abortions you've had.
- Your childhood and adulthood immunizations.
- Any health screening results, such as those for blood pressure, cholesterol, vision, and hearing.
- Any cancer screenings, such as Pap tests , mammograms , colonoscopy , and PSA (prostate-specific antigen) tests .
- Any surgeries or times you were in the hospital.
- Your hearing and vision checkups.
- Medicines you've used in the past.
Your family history
Keep records of major health problems in your family, such as heart disease, stroke, cancer, or diabetes. To keep track of your family health history, use this form (What is a PDF document?) or go to the Surgeon General's family health portrait website at www.hhs.gov/familyhistory.
What should you keep with you?
Always carry these with you:
- Identification, such as a driver's license
- Who to call in an emergency
- The name and phone number of your primary doctor
- Your insurance card
- Your organ donor card, if you have one
Other Places To Get Help
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
Specialist Medical Reviewer E. Gregory Thompson, MD - Internal Medicine
Current as ofSeptember 9, 2014
To learn more, visit Healthwise.org
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