How to Obtain, Read and Understand Your Medical Records

Managing your healthcare can be a difficult and frustrating task. Confusion about your health insurance, and keeping track of medications, doctors and procedures can be time consuming, and nearly impossible, if you are very ill. Barack Obama's stimulus plan currently includes 20 million dollars for the digitization of medical records. The hope is that by doing this, patients and doctors can access their medical records online, simplifying a patient's care. Until this happens, being a good patient includes gathering copies of your medical records and keeping them for reference. So how do you obtain, your medical records?

Your first step is to make a list of all doctors you have seen, now and in the past. List hospitals, clinics, and labs you have visited as well. Find addresses and telephone numbers for them. It's an incredible time saver to make a quick call to the provider and ask them what they require from you to obtain your records. Almost always, a provider will request a HIPAA authorization, signed and dated by you, in order for them to release your records. Many providers have their own form they will send you, however there are HIPAA forms online for your state that can be used. So what is a HIPAA authorization?

HIPAA stands for Health Information Portability and Accountability Act. The authorization form that you fill out includes your signature, date, the time frame for records requested, and will ask if you want psychiatric records, etc. included. This authorization protects your information from being distributed to the wrong parties, and ensures the privacy of that information. The HIPAA form also has an expiration date for the signature, meaning that after 90 days, or one year, the HIPAA form is no longer useable and a new one must be filled out. Once the form is returned to the provider, they will search for your records. Most providers have up to 30 days to return your records to you, although many large hospitals take longer. Quite often there is a copy fee and a handling fee involved with your records request. Once the fee is paid and your records are in your hands, how do you read and understand any of the information within your records?

If not already done, sort the records in date order, from past to present. Note that records are divided into different types of reports. For example, look for reports titled "Discharge Summary," "Operative Report," "Lab Report," "Nurses Notes," and "Progress Notes." Read through each of the reports, marking areas you do not understand. Use the internet to look up medical terms and types of tests performed, or call the doctors office if you need something clarified. When reading through your medical records, note medications prescribed, procedure dates and treatments rendered. When finished, store your records in a safe but handy place for future reference. Keeping your records with you, especially if you move or become very ill or injured, can save providers time when treating you.

Knowing how to obtain and understand your medical records is an important part of being a healthy person and a happy patient. Your medical records are invaluable to doctors and hospitals as well when managing your care. Ensure you get the proper care by knowing and understanding your medical history through your medical records.