Organizes And Codes Patient Records

Gone are the days when people kept their family physician past childhood through young adulthood and parenthood and into old age. Now most health care consists of an assortment of primary care physicians and specialists, supplemented by visits to urgent care clinics and emergency rooms. Unfortunately, that patchwork of health care often comes with a disorganized collection of medical records, to the point where it's unlikely that any one doctor knows a patient's entire health history.

That means it's up to you to provide that history. And, no, you don't have to track down your old pediatrician; he or she probably doesn't even have your paper records anymore.

If your doctor is one of the many who have switched to keeping patients' records digitally, the task of compiling your history will be easier. There are two kinds of digital records: electronic medical records and electronic health records. An EMR is a digital version of the records individual doctors keep—it's like your doctor's old medical chart, but now on a computer. EHRs are designed to help share information among different doctors and hospitals—and with patients, too.

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Since January 1, 2014, all public and private health care providers have been required to adopt and demonstrate "meaningful use" of EMRs in order to maintain their Medicaid and Medicare reimbursement levels. There were additional incentives for health care providers who adopted EHRs.

There are clear benefits to electronic record keeping. Besides eliminating the headache of paper files and making it easier to share information, digital records may save lives, explains Lesley Kadlec of the American Health Information Management Association. Emergency room doctors no longer have to waste time dashing to the records department for the chart of a patient who was just admitted—they can simply call it up on a computer screen.

There are stumbling blocks, however. For starters, because EHRs are a recent phenomenon, everyone has a medical history of appointments and treatments that occurred before digital records existed. It's also surprisingly difficult, given the ease with which other information is shared online, to swap records between your primary care doctor and a specialist's office if they don't use the same EHR system. Compiling your history may still mean contacting many different providers. (Should you see a female doctor if you have the choice? Here's what the research says.)

Here's what you need to have in your possession and how to find it.

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A list of all current meds

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Keep a list of what you've been prescribed plus anything else you're taking, says Lynne Lillie, a family physician in Rochester, MN. "It's important for a doctor to know everything a patient is taking," she says, including vitamins and supplements—many can interact with prescription drugs. (These are the 7 things pharmacists want you to know but will never tell you.)

If you see different doctors who prescribe meds without consulting each other (and don't share an EHR system), they can refer to your list before making any new drug recommendations, says Navya Mysore, a primary care physician with One Medical in New York City.

WHERE TO GET IT: Start by writing down, typing up, or photographing the labels of your current prescription meds, including drug name, dosage, and instructions. Contact the prescribing doctor for any missing information. Then add to the list any vitamins, supplements, and other diet, nutrition, or weight loss aids you take.

A description of your chronic medical conditions

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If you've had care for an ongoing health problem such as asthma or diabetes, you've likely tried several treatments. It's helpful for your doctor if you keep track of what you've already tried, what's worked or hasn't worked, and what kind of progress you're making.

WHERE TO GET IT:If you received your diagnosis within the past 7 to 10 years, those paper records may still be available. But if your diagnosis was made before that, your doctor may have discarded them. In these cases, do your best to recall the earliest stages of your condition and treatment and write down what happened. Consult other doctors who have treated you since then to obtain your records.

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A log of past procedures

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Making sure your physician understands what kinds of medical procedures you've had in the past can affect your future treatment. If you had a mastectomy, for example, your doctor will tailor ongoing breast cancer screening to your personal history. If you've had several cancerous moles removed, a doctor will want to keep a close eye on other suspicious spots. Include outpatient and in-office procedures in your log.

WHERE TO GET IT:You probably remember big surgeries and procedures, but if you're unsure, consult the insurance companies you've used. They should be able to provide you with a list of the treatments and procedures doctors billed them for over the period you were covered, says Dan Greden, head of e-health products and clinical innovation for Aetna.

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A copy of recent test results

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The results of cholesterol, blood sugar, and blood pressure tests provide a baseline for any doctor to get quick insight into your overall health, Mysore says. If you're being followed for specific conditions that require frequent workups, such as anemia or hypothyroidism, include those numbers, too, as well as results from regular screenings like Pap tests and mammograms. (Psst! These are the 9 most important medical tests for women.)

WHERE TO GET IT: Request a copy of the past 2 years' blood work and screening results from your most recent physician.

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A list of immunizations

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"A lot of patients have no idea what vaccinations they've had," Mysore says. "For certain vaccines, we can run a blood test to see if they've been immunized."

WHERE TO GET IT:Contact your past physicians to see what's on record.

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Your family history

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Your family medical history can play a big role in indicating whether you should undergo early screening tests for conditions such as heart disease, diabetes, elevated cholesterol, and cancers of the breast, colon, or prostate, Lillie says.

WHERE TO GET IT: Talk to family members about their past health problems. It's not always a cheery conversation, but it could save your life.

How to organize your health records

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GO DIGITAL.
Type up lists of your medications, vaccinations, and family history, and scan copies of imaging and other test results. Then save everything to an online file-sharing program like Dropbox or Google Drive.
OR STICK WITH PAPER.
If you're more comfortable with paper records, keep the most important information accessible so you can take it to appointments. Organize and store older, less important information.
KEEP THE ESSENTIALS.
How long to hold on to medical records varies from person to person. You should keep information about treating your lifelong allergies, for example, but you don't need decades' worth of blood test results.
STAY UP TO DATE.
Once you've compiled your medical history, keep the records up to date by adding to them each time you have a doctor's appointment, get new test results, or receive a new prescription.

Sarah Klein Sarah Klein is a Boston-based writer, editor, and personal trainer currently with LIVESTRONG.com, and previously of Health.com, Prevention magazine, and The Huffington Post.

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