Physicians and health care providers keep medical records to better understand a patient’s prior care and to help inform their decision for treatment plans. Developing your own system for organizing medical information, or creating a personal health record (PHR), will help you stay on top of doctor’s visits, medications, and insurance claims. Providing your own medical records may help you receive safer and quicker treatment if you change doctors, move, get sick, or end up in an emergency room. “Organize Your Medical Information Month” in October is an opportune time to gather and catalog the medical documents you need. However, seize any available day during the year to get organized. Having your documents in order will also make it simpler to review and consider changes to your Medicare coverage during events like Medicare’s Annual Enrollment Period (AEP) from October 15th through December 7th.
When deciding how to organize medical paperwork for yourself or another as a caregiver, develop a system that works best for you and is easy to transport, store, and update. Consider using a three-ring binder or file folders. If you have the capability, make duplicate electronic copies of scanned or photographed documents and save them on your computer to mirror the organization of your paper files, or use a software tool made specifically for medical documents. The first page of your personal health record should include your name, date of birth, blood type, and a table of contents. The remaining information is customizable, but the following steps will help you navigate the process when creating your personal health record.
Step 1: Locate and keep copies of medical records.
Call your doctor to request copies of your medical records and let them know you’re creating a personal health record. Your doctor may also be able to help you find your medical records online, at hospitals, or other health care facilities. You’ll need to sign a release form, provide a valid government-issued photo ID, and you may be required to pay a fee. If you’re a caregiver and requesting records for someone other than yourself, facilities will only release them if a direct authorization to disclose records to a third-party form is signed by the patient. Most requests can be fulfilled within 5-10 business days; however, HIPAA (Health Insurance Portability and Accountability Act of 1996) allows providers 30 days to complete a record request, plus a single 30-day extension.
Step 2: Organize medical history and current health information categorically and chronologically.
Every individual has a different health history, therefore how you categorize your records is a personal decision. Your current and past health information may include:
- Doctor office visit information (date, doctor name, and notes)
- Dates and results of tests, procedures or health screenings
- Information about any major illnesses, surgeries, or hospital visits
- A history of any counseling received
- Hearing, vision, and dental records
- History of childbirth
- Immunizations records
- Cancer screenings, including Pap tests, mammograms, colonoscopy, and PSA (prostate-specific antigen) tests
- Information that is needed in an emergency (e.g., a pacemaker, stent or hearing and vision problems)
- A list of long-term (chronic) health problems, such as arthritis, asthma, diabetes, or high blood pressure.
- A list of allergies, including drug or food allergies
- Family history of disease
- Medicines taken in the past and present, including any side effects (see step 3)
Step 3: List all current and past medications and prescriptions.
Include a list of current and past supplements, prescriptions, and over-the-counter medications. Write down the drug name, dosage, start date, end date, and the condition it is treating, plus any side effects experienced.
Step 4: Keep track of billing and insurance documents.
In chronological order, organize copies of all bills and receipts from doctors’ offices and any insurance payment documentation (explanation of benefits forms). Keep records of insurance claims, payments, and balance information. Include a log of phone conversations with insurance representatives, including the date and name of the person you spoke with. Include a copy of your insurance and Medicare card.
Step 5: Create a list of important contacts.
Record names, medical practices, addresses, telephone numbers, and email (if applicable) of your doctors and pharmacist. Include the emergency contact information of a caregiver, family member, or friend in case of an emergency. Include the name, policy number, address, and telephone number of your health insurance company.