Health Perspectives

Maintain Your

Medical Records

Mary Ann Ryan

If you don't know your own medical history, you may be doomed to repeat it.

Who is in charge of monitoring your health: you or your doctor? If medical care were as simple as it used to be (or seemed), when most people had one family doctor for many years, the answer would be straightforward: The doctor’s in charge. But health care has become an increasingly complex affair for most of us. To achieve the best health outcomes, both patient and doctor now must act as partners in gathering data, organizing medical information, making decisions, and coordinating treatment. One way to facilitate this process is to build a medical history file of your own. By doing this, not only will you better understand your own medical history and be able to communicate it accurately to health professionals, but you can also gain greater control over the management of your health.

Nothing underscores the need to be an active participant in your own health care like the current managed care environment in which we all find ourselves. With doctors under pressure to increase patient loads and often given incentives by health maintenance organizations to limit the time and treatment options for each patient, your ability to communicate medical needs quickly and effectively becomes paramount. No matter how concerned a physician may be about your health, he or she is most likely taking care of many patients every day, spending the briefest possible time with each one, and trying to absorb the maximum amount of information on the medical condition of each.

Another reason to play an active role in tracking your medical history is the frequent and often unexpected changes in health care providers that you are likely to encounter for various reasons. Changes in employers’ health insurance benefits often lead to a change of health care providers. Many individuals have had to seek new doctors to receive full coverage under preferred provider plans or other restricted health insurance policies. Career changes may bring geographic moves that require you to find new doctors and other health professionals. Even if you remain in the same area, you may, at various times, require the services of multiple health care providers in addition to your primary care doctor: specialists such as orthopedic surgeons, physical therapists, gynecologists, or urologists—just to name a few. If you develop a medical condition like arthritis or cardiovascular disease, then you will require even more specialists.

Add up these visits over a period of years, and you will have a lot of medical data that need coordination to be used effectively. If you want, you can rely solely on your memory to provide the patient history that you will be asked for in every office you visit, or leave it to busy doctors’ offices to communicate your essential medical information in a timely manner when you need it. But memory is an unreliable tool at best, especially as you get older and have more to remember. And the files in doctors’ offices are (understandably) not always well organized or easily accessible on short notice.

Marvin M. Lipman, M.D., clinical professor of medicine at New York Medical College and chief medical adviser to Consumers Union (publisher of Consumer Reports magazine), writes: “I often encounter . . . lapses of memory and errors of omission while collecting information from patients. Dates and details of everything from immunizations to hospitalizations tend to become blurred by the passage of time. . . . Medication histories, in particular, are often shrouded in mystery. Nowadays, more patients keep track of the names and purposes of the medications they take, but many still don’t. And even those who know what they’re taking often can’t recall the medications they’ve taken in the past, including drugs that didn’t help or that caused side effects” (1).

Why Compile Your Own Medical History? Geographic moves, changes in insurance coverage, or development of new medical conditions may require you to interact with different health care professionals who will need your medical history. Keeping copies of your own medical records lets you provide essential medical information to doctors and other health professionals quickly, easily, and accurately. You can prepare a brief summary of your medical history as well as current medications and dosages to let the doctor know key facts up front without a lot of digging. You will have documentation of blood test results and other medical tests that can be used for baseline reference or monitoring of a condition over time. Allergies or other negative reactions to medications are clearly documented. You may be able to avoid unnecessary testing or ineffective treatments if you have documentation of what has been done in the past. All of this information will be in your own hands to be used most effectively; you won't have to depend on doctors' offices to organize it and forward it in a timely manner.

A Personal Example
Having lived in six different regions of the United States over the course of my career, I have had considerable experience with the issue of gathering and communicating medical information to new health care providers. In earlier years, if I gave any thought to medical records at all (which I often didn’t), I relied on the traditional approach of having the previous primary physician’s office forward my records. I learned that this method poses several problems. First and foremost, it kept me separated from my own medical data. By being transferred directly from one doctor to another, the records didn’t pass through my hands. How could I ensure that all pertinent information was forwarded, that it was accurate, or that it was in an easily understandable form? Second, I had to rely on the services of increasingly busy medical offices to duplicate and mail records in a timely way when I needed them. Third, in cases in which I did not have my medical file forwarded soon after leaving an area, I later found that some records were difficult to locate because they had been archived. In a few cases, I couldn’t even remember the names of the doctors I had seen or how to contact them without digging through old files in the attic to find bills or insurance records.

I then had an experience that convinced me to find a better method of dealing with medical records and build my own health portfolio. About 10 years ago, I went into a hospital to have surgery for a foot problem. One of the routine tests done before any surgery is an EKG (electrocardiogram), and in this case, it was done on the same morning as the surgery. When I was about to be wheeled into the operating room, the orthopedic surgeon came to my bedside, in full surgical garb, and said he could not operate because the EKG showed a particular pattern that could be indicative of a previous heart attack. He said, “Since I can’t tell whether it happened 10 years ago or an hour ago, I can’t take the risk of putting you under anesthesia.”

My reaction was not fear, but annoyance. I had never had the slightest heart trouble. I knew that prior EKGs done as part of physical examinations had been normal. I was sure there was some mistake. Having taken time off from my job for the foot surgery, I would now not only have to reschedule it for another time, but go through further heart tests to convince the doctor that I was OK. After I tracked down EKGs from a doctor in one of the places where I had previously lived (a time-consuming process), it turned out that the supposed abnormality that the surgeon detected had been present for years and had been declared a “normal variant” rather than a sign of heart disease. A full battery of heart tests bore this out. But lacking that information, the doctor had proceeded in the most conservative way. Had I presented him beforehand with my medical records, including EKGs, this issue would have been cleared up ahead of time, and the surgery could have proceeded.

"Begin by asking your current physician and any previous physicians that you can contact for a copy of your medical records."

Organizing Your Information
Think 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 to date becomes easy when you have done the basic work of acquiring your previous records.

Conclusion
Your 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.

Reference
(1) Lipman, M. M. Keeping Your Own Medical Records. Consumer Reports on Health, 1993, Oct., 115.

Mary Ann Ryan writes on health and science topics. She holds an M.S. degree in analytical chemistry and a Ph.D. in chemical education from the University of Virginia. Comments and questions for the author may be e-mailed to tcaw@acs.org, faxed to 202-776-8166, or mailed to Today’s Chemist at Work, 1155 16th St. NW, Washington, DC 20036.

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