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If you are like the average person, your doctor(s) have made many notes about you over your life span. These notes make up your medical records. These records are kept by your doctors or any hospitals you have been treated in. It is important to know what is in your records. Keeping a copy of your (or your family’s) records in a safe place is a very good idea.

Medical records: what are they?

Your file can be thick or thin. Your age and your level of health will determine how thick the file will be. Each person is different and there are many different things that can be in your file. Here are a few of the things you might find in your records:

Biographical information: age, occupation and other factors that may effect your health.

Medical and Family history: information on surgeries or major illnesses. Information on things that may run in your family such as some forms of cancer.

Medical diagnoses: every time your doctor makes a decision about your symptoms it will be entered into your record.

Test result: from blood tests to cat scans, all results are sent to your doctor and then put into your records.

Medication records: records the name of the drug and the dosage.

Doctor’s order: any specific treatments that your doctor prescribes.

Progress notes: these show how your treatment is coming along.

Obtaining your medical records:

First thing to do is ask. Call your doctor’s office. They should offer to photocopy your records for a reasonable fee. Put your request in writing. The letter should include all the pertinent information: name, address, patient id number (if you have one) and the records you want. If your request in refused ask for a letter stating the reasons for the refusal.

If asking fails, talk to a lawyer. You may be able to get a court order requiring your doctor to hand over your records. In the US you can also contact the Medical Information Bureau (MIB) if you’ve had an insurance claim the MIB probably has a file on you.

Keep your own records:

There are always mistakes. If you keep track of your own health care records you will be in a better position to make informed decisions. Record every visit to your doctor or hospital. Make sure you have the date, doctor’s name, symptoms, diagnosis and treatment suggested.

Keep a record of all your major hospitalizations. Here is where you keep track of anything that happens. Record all the same information you would for a normal medical visit. You should also include admission and release dates, the name and address of the hospital, name of admitting doctor and any consulting doctors. Also include tests, treatments and medications given each day.

The last record you should keep is that of your medications. This should be a list of all prescription medications you take, what you take it for, the dose. You should also record who prescribed the medicine, when and where the prescription was filled and any side effects you’ve experienced with the medication. You should also add any over the counter medications you take on a regular basis.

Keeping good records will give you the best chance at good health care. If you write down the results of any medical consultation or treatment right afterwards, you will soon find yourself in the habit. The next time you have a medical emergency, you’ll be glad you did.