Grand Rounds Blog

Why is it that every time you visit a doctor, you are asked to complete a medical history form? I’ve filled out dozens of these forms, each time wondering “why doesn’t my doctor already know this?’, “don’t my doctors talk to one another?”, and “why am I filling this out – again?”.  Related, I’ve had a doctor tell me, “that wasn’t in your medical record”, which led me to believe I had one shared record amongst my physicians. I mean, it’s technically feasible, so this seemed a reasonable assumption. But you know what they say when you assume…..

What is your medical record(s)?

I, like you, have medical records – plural. Each physician creates a medical record.  Your medical record contains information like notes and observations from your office visits, surgical information, treatment notes and plans, prescriptions, etc. Creation and storage of that record varies by doctor, or doctor’s office; it could be a paper or digital record.

If your medical record is digital it should be stored in the standard HL-7 format (think of HL-7 as like a Word document – stored in .doc format). Your digital record could be stored in any one of dozens of different EMR (electronic medical record) systems (an EMR is like a big digital filing cabinet). And here’s the kicker – just because your medical record is digital, and in the HL-7 format, it doesn’t mean your medical record can be easily shared between EMR systems.

Most doctors’ offices have not yet integrated their EMR system with EMR systems at other institutions.  This means the “integration” is up to you – the patient.

The Affordable Healthcare Act and meaningful use incentives are helping to pave the way towards easier access of your medical records by incentivizing doctors to store your medical records digitally, and to make their systems interoperable. However, this is a multi-year, multi-phased plan. The 2014 reality is that getting copies of your medical records is not only a royal pain-in-the-behind resulting in many faxes and snail mail, but it can take up to 30 days to receive your medical records (time to respond to requests varies by State law, but federal HIPAA law limits the response time to 30 days).

Why should you have copies of your medical records?

ICE – In Case of Emergency. If you have a medical emergency, waiting up to 30 days for your records could be detrimental. Having a copy of your medical records could at best save your life, and at worst help you and your attending physician to make better-informed decisions for your treatment.

Facilitate physician communication.  There is no one, shared medical record. It is the patient’s responsibility to make sure her doctors stay informed. By keeping up-to-date copies, you’ll have your records to share at your next appointment. No waiting. No trying to remember what the other doctor said.

Play an active role in your own healthcare. Having a copy of your records allows you to (1) check the records for accuracy, and request changes if needed; (2) track your progress against health-related goals; and (3) easily refer to physician instructions, prescriptions, vaccinations, and food & drug allergies.

You are your best advocate. Make sure you have your necessary tools on hand. If you don’t already have your medical records – go get ‘em!

Upcoming post: How to request your medical records

Note: As part of the Grand Rounds Expert Opinion and In-Person Visit services, your Care Team will collect your medical records for you! Your medical records will be stored digitally as part of your account so that you can always access them. 

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