But I thought you have my medical records, doctor?

September 8, 2011

Mark L. Friedman, MD, FACEP, FACP

This is a common refrain from patients as I try to take a medical history. Check which one(s) apply to you:

"I have just given this information to the nurse."
"It's all in my file."
"I was here last week."
"Dr. Jones has all my records."
"The hospital has my records."

All too often, unfortunately, this is just not true. An individual's medical records may be uncoordinated, fragmented, incomplete, full of errors and omissions, or simply unavailable.

The best solution is for you to obtain, keep, and periodically update your personal medical records. Fortunately, this is much easier to do in the computer age.

Start by compiling a "problem" list of your medical issues. You can get this from your primary care doctor, a hospital discharge summary, or even your own memory. Include both active problems for which you are currently being treated, and those you have had in the past, as well as a list of current medications and any medication allergies. Vaccination history (when was your last tetanus shot?) and family history can be important as well. Images from your EKG, chest X-ray, and MRI scan may be important in specific cases. Contact information for your doctors and hospital records may be useful, as well as your insurance information.

This should be summarized in 1 to 2 pages. Additional documentation (images, reports, etc.) can be appended as necessary. Print out the summary and carry it with you to the doctor. Store it on your email server (and/or a medical record storage service) so that it is available anytime from anywhere. If you cannot do this yourself, you may wish to retain a patient advocate or a medical professional to do this for you. Consider it for family members also.

This is your medical record. You should have a copy. After all, the life and health at stake may be your own.


Originally published Sep 8, 2011 6:04:37 PM.