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Home Medical Records


Overview

Where are your medical records?

Probably with your doctor, as they should be. Your doctor needs these records to track your care and provide the best treatment.

But it's also a good idea to have your own copy of your health records.

Your medical records are called your personal health record, or PHR. And when viewed over the Internet, health records are called an electronic health record (EHR) or electronic medical record (EMR).

You'll need your health records 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.

Keep a summary of your PHR in a safe place. And be sure that someone you trust also knows where you keep it.

What to keep with you

Keep personal information and current and past health information.

Personal information includes:

  • 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.

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 medicinesClick here to view a form.(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 also is important. Keep track of:

  • Major health problems you've had in the past, such as pneumonia or broken bones, or problems with alcohol or drugs.
  • Major health problems in your family, such as heart disease, stroke, cancer, or diabetes.
  • 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.

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.

To keep track of your family health history, use this formClick here to view a form.(What is a PDF document?) or go to the Surgeon General's family health portrait website at www.hhs.gov/familyhistory.

What to keep at home

Having medical records for each member of your family can help you make better health decisions. Records to keep include:

  • All the information noted above.
  • An immunization record with dates of 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.
  • Records of any major surgeries or times you were in the hospital.
  • Records of your hearing and vision checkups.
  • A list of medicines you've used in the past.

If possible include:

  • A copy of your advance directive, including a living will and power of attorney.
  • Your pharmacy name and phone number.
  • The poison control phone number (1-800-222-1222).
  • Records of insurance claims and payments.
  • Written notes from your doctors or doctor visits.
  • Anything else about your health that you think is important.

How to get started and store your medical information

Get a copy of your health records from your family doctor and anywhere you've received health care. 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 may need to sign an "authorization for the release of information" form. You may need to complete this form for 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. You also may be charged for mailing fees. Ask how long it will take to receive your copies.

After you have your information, you need to organize it. Here are some ideas:

  • 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.
  • Create a file on your computer with your information. Create the file in any software program you feel comfortable using.
  • Use software that creates a personal health record.
  • Store your health records on a secure Internet site. Your health plan or hospital may have one.

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 records. Go to www.myphr.com.

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