Requesting your medical records is not only the smart thing to do, it’s your right. It allows you to update any information that may be important to your care or to question your doctor about anything that is missing or incorrect.
According to HIPAA, you have the right to request medical records if:
- You are the patient or the parent or guardian of the patient whose records are being requested.
- If you are a caregiver or advocate who has obtained written permission from the patient.
If your loved one is in the hospital, the last thing you want to think about is if you have all the right medical records to receive the proper care. You can create a personal health record (PHR), for yourself or a loved one to ensure nothing is forgotten. We talk more about this in an earlier post.
Often there is a long wait to receive these records, to avoid this in the future we recommend creating your own personal health record (PHR), to have on hand in any situation. In the future, you can simply ask for the records as they are created instead of when an emergency occurs.
If you are not quite ready to create a PHR for your medical records, here are 7 medical records to request as you go forward in your caregiving journey.
You will want a copy of all test results. Consider that not all test results are written in layman’s terms. Medical professionals are required by law to ensure you understand what the lab results mean. So if you get a copy, you can get an explanation of the results and write your own notes down related to their description.
A treatment plan is the description of how the physician plans to treat the illness. The plan should have all the steps listed that should be taken next. For example, the treatment plan could say you need a follow up visit or perhaps you need a referral to another doctor. If you don’t understand something on the plan, similar to test results, your medical team is required to ensure you understand. Ask whatever questions you need to know so you can be educated, that way if you need to provide these documents to a doctor that might not be familiar with your care, all information will be provided.
Clinical Visit Summary
Many of the new electronic medical record systems print a visit summary automatically and the doctors are often required as a part of the health system they work with to provide a visit summary. However, if you don’t get a visit summary, it is good to request one after each appointment. The summary will include things like the doctor’s contact information, follow up steps, tests that were ordered, instructions for care, and many other important details.
HINT: If you are using an electronic app like the Mindlight app, this is a good document to take a quick photo of and store in the virtual file cabinet. All of the other caregivers that you provide access to will be able to read all the visit summary information and know without you having to tell them what is going on.
Resources About Disease
In a prior blog post we discussed what to do on diagnosis day. One of the first suggestions was to do some research on the diagnosis. Your doctor or nurse often will print or hand you educational materials about your diagnosis. Many times the information gives good tips and tricks on how to manage your illness at home.
HINT: This is also a good document to share with your care team electronically.
Doctor Contact Information
This seems like a simple thing, but it is easy to forget if you are going to a lot of doctors or have a number of specialists. Consider getting the business card of the doctor. You will want the doctor’s name, the nurse’s name, and the facility name, and the phone and fax numbers for the clinic. It is also a good practice to write down any other assistants names that might have interacted with you.
HINT: This is a great way to use apps like the Mindlight app. You can either take a quick photo of each of the business cards and store them in the virtual file cabinet, or you can enter then in the shared contacts section. This will also allow you to share all of these details with all the other caregivers that are assisting you.
You are going to be managing a lot of paperwork and a lot of bills. A superbill lists all charges and codes that define your services and how much you have to pay out of pocket. Don’t throw this or any other receipt for payment away. You want to periodically ensure you are not getting billed incorrectly. If you have a lot of different doctors and specialists sometimes they will even order the same tests. Having the bills to link to the visit summaries can give you are bigger picture of what is going on with care.
HINT: If you store all of these in the virtual file cabinet you will have an online record of all the payments and charges. If you have another person that does the financial part of caring for the person you are caring for, they will have everything they need without having to ask you.
Current Medication List
Often you will be given a current medication list to review at each new appointment. However, if you don’t have the prior list or you are not the one managing the medications it can be difficult to ensure that not too many or too few medications are given. If you get an active medications list at each appointment and you check to be sure it is accurate, you can save potential costs as well as prevent an adverse reaction if one of your medications is not listed and could react with something the new doctor prescribes.
While there is a lot of paperwork and things to consider at each doctor appointment, this is the area that is often managed much better using a technology solution like the Mindlight app. The app is HIPPA compliant so you know your information will be secure.
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Source: Loosely adapted from “The Caregiver’s Toolbox” by Carolyn P. Hartley, MLA, and Peter Wong.
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