Keeping Track of
Your Health Information
By Carolyn M.
Clancy, M.D.
June 16, 2009
Say you’re out of
town, and you become ill. You go to the local
hospital emergency room, where you are quizzed
about your medications and allergies.
Unfortunately - in the confusion and stress of the
moment - you forget to mention that you’re
allergic to penicillin until it’s too late.
It’s not
farfetched. Visiting a hospital or a doctor can
be a stressful experience. Some situations - if
you’re weak from illness or a trauma, or are in
place you don’t know - may be confusing. You may
not be able to remember every important detail.
But, good health
care depends on good and thorough information.
Your health information - the medicines you’re
taking, your allergies, your family history,
what illnesses or surgeries you have had - is what
makes you medically unique, and can affect your
treatment. The one thing you forget to mention
could be the detail that might save your life.
Many Americans
receive care from doctors in many places. We are
a mobile society; we change towns, we change
doctors, we change jobs and we change health
insurers. But, your doctor’s medical charts and
other health information don’t automatically
appear at different doctors’ offices or
hospitals. Don’t assume your doctor has all the
relevant information at his or her fingertips.
Usually, in fact, the doctor does not.
Because of this,
it’s up to you to keep track of your own health
information.
Some people do so
by creating and maintaining a
personal health record (PDF file, 225 KB;
PDF
Help), or PHR. PHRs typically are health
records that can be offered by your doctor or
insurer but are maintained by you, the
individual (rather than by a provider or
insurer). Usually, you control who can see or
use the information in a PHR.
An ideal PHR
provides a complete summary of your health
history by compiling information from many
doctors and other care providers. In some cases
it makes information available via the Internet
to anyone you allow to see it. Other types of
PHRs can be saved on your computer.
If you’re
comfortable storing and updating your
information in this fashion, a PHR may be for
you. If not, you should keep track of your paper
records by storing them all in one place. You
should organize these records in a way that you
find useful, and make sure that a friend or
family member knows where to find them. Keep in
mind that
Federal privacy rules (PDF file, 337 KB;
PDF
Help) give you rights over your health
information, but allow this information to be
passed along at certain times.
Some
Medicare and prescription drug plans offer
PHRs. If you belong to one of these plans, check
your plan’s Web site or contact the member
service department to see if one is available.
There are two
important reasons to keep good records about
what has happened with your health care. The
first is that your record could be the only
information source at critical moments, such as
an emergency. (Even if you’re only able to offer
basic information to new doctor at that time,
that information can be very helpful.) The
second is that keeping your own record helps you
take better care of yourself and helps you ask
better questions about your care.
What kind of
information should you keep track of? Anything
that may affect how a doctor might treat you. At
a bare minimum, you should list, in detail,
information on the following:
- Any
illnesses or conditions in your own history,
such as whether you have heart disease.
- Any
potentially relevant family history of
illness (such as diabetes, cancer, or high
blood pressure).
- Prescription
medicines you’re currently taking, including
dosage information.
- Known
reactions to medications or allergies.
- Test results
and immunization records.
You also should
include information on over-the-counter
medicines and vitamins you regularly take and
preferences such as a living will on your
record. And, the names and phone numbers of your
doctor(s) and insurance company also are
important.
You can add more
information to your record as you see fit. Some
PHRs give good guidance on what to add, and a
number of organizations offer guidance on how to
select and use a PHR. Your PHR doesn’t have to
be fancy, but it should be organized. What’s
important is that the information you put in
your record be as complete, accurate, and
accessible as possible.
I’m Dr. Carolyn
Clancy, and that’s my advice on how to navigate
the health care system.
More Information
MedlinePlus
Personal Medical Records
http://www.nlm.nih.gov/medlineplus/personalmedicalrecords.html
Centers
for Medicare & Medicaid Services
Learn More About Personal Health Records
http://www.medicare.gov/phr/LearnMoreAboutPHR.asp
Department of Health and Human Services
Privacy and Your Health Information
http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/consumer_summary.pdf
[PDF
Help]
Current as of June 2009
Internet Citation:
Keeping Track of Your Health Information.
Navigating the Health Care System: Advice
Columns from Dr. Carolyn Clancy, June 16, 2009.
Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/consumer/cc/cc061609.htm
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