Your Medical Records

Don't look now, but you're being followed. You have been, in fact, since the day you were born. The good news is that the people following you are doctors, nurses, and other health care providers. And the way they're tracking you is on paper, through your personal medical history.

What Are Medical Records?

Each time you hop up on a doctor's exam table or roll up your sleeve for a blood draw, somebody makes a note of it in your medical records. All that scribbling adds up over time. Even if you're the healthiest person alive, you'll still manage to accumulate crate upon crate of paperwork by your 21st birthday.

Chances are you won't ever pore over all those pages. But there might come a time when you want to get information from your medical records: Maybe you'll need to provide your college or new job with a record of immunizations before you can start. Or perhaps you want a new doctor to know your full medical history.

As you start taking charge of your own medical care, it helps to know what's in your medical records, how you can get them when you need to, who else is allowed to see them, and what laws are in place to keep them private.

What's in My Medical Records?

You might picture your medical records as one big file in a central storage facility somewhere. But actually they're in lots of different places. Each specialist who treats you keeps his or her own file, and each of these is part of your medical records.

Your medical records contain the basics, like your name and your date of birth. They also include the information you give to your family physician, dentist, or other specialist during an examination.

You know how doctors often ask a series of questions — like about how you're feeling that day or your family medical history? Well, all of your answers go into your doctors' records, along with the results of any medical exams, test results, treatments, medications, and any notes doctors make about you and your health.

Medical records aren't just about your physical health. They also include mental health care. So if you went to family therapy back when you were 6 and your parents were divorcing, it will be somewhere in your records.

Can I See My Records?

U.S. law gives patients the right to see, get copies of, and sometimes even change their medical records.

If you're younger than 18, your parent or guardian will probably need to ask for copies of medical records on your behalf. However, more states are allowing minors to take charge of their own health services, so ask your doctor, hospital, or health system about what access you have to your records.

Medical records — particularly test results or imaging studies like X-rays — can be confusing for people who aren't trained in reading them. Something that might look scary on an X-ray or MRI might be nothing to worry about. So if you do look at your records on your own, keep that in mind and ask a doctor if you have questions.

How Do I Get Them?

Start by figuring out who has the information you want. If it's dental information you're after, contact your dentist's office. If it's a general health issue, you'll probably want to talk to your family doctor.

When it comes to requesting medical records, different providers have different ways of doing things. Some might ask you to fill out an authorization form. If so, you'll want to be ready with information like this:

• Dates of treatment or service (such as a hospital stay). If it's been a while and you don't remember exact dates, ask for records from a range of dates, such as 2000-2005.

• Which information you want. Do you need the entire record or just part? Specific test results? X-ray films, blood work results, etc.?

• How you want the information. Do you just want to look at your records to find out what's in them? Or do you need to get your own copy, have a copy sent to another physician, or both?

A health care provider's office might charge a fee to cover the cost of having someone make copies. Some offices put test results and imaging studies on a CD-ROM. You'll probably have to pay for mailing the records to you or another doctor (if you won't be picking them up in person).

How Long Does it Take?

The law gives health care providers up to 30 days to provide copies of medical records, but almost all health care organizations supply records a lot faster than that. Most people get their non-critical care records within 5 to 10 business days. If records are needed faster — like when a patient needs medical treatment — the health care provider holding the records usually releases them immediately.

If you need to get records for non-emergency situations (such as switching to a new doctor), it's safest to give plenty of notice. Let the medical provider who has your records know that you'd like copies a few weeks ahead of any appointments with your new health care provider.

Can They Say No?

They can — but it almost never happens. When it does, it's because a doctor's office is trying to protect a patient's privacy or safety. For example, they may withhold medical information if they're not sure the person requesting the records has a right to see them. Or they may not release records if they think it will lead to the patient being harmed.

If health care providers deny access to records, they must give the reasons why in writing within 30 days. If any request for medical information is denied, a patient has the right to ask for the decision to be reviewed again.

What if I Spot a Mistake in My Medical Records?

If you notice something missing or something you think is wrong in your medical records, you have the right to request a correction. Ask your doctor's office to explain how they handle changes to your records and what you need to do to request a change. The law gives health care providers 60 days to make the changes or deny the request.

Who Else Can See My Records?

Your information can be used and shared with the following people or groups, when needed:

• other health care providers as necessary to support your treatment and care

• insurance companies, Medicaid, and other groups responsible for paying doctors and hospitals for your health care

• public health agencies as needed to protect the public's health, such as by reporting when the flu is in your area

• law enforcement agencies, such as reporting a gunshot wound to the police

• parents or guardians if you are younger than 18

• family, relatives, friends, or others in your life — but only if you (or a parent or guardian, while you're under 18) give permission

What About My Parents?

Parents have access to their kids' medical records until the child is 18. However, many states now allow doctors to decide whether or not they disclose certain information to parents — like about sexual health or substance abuse, for example. The law also states that parents no longer have access to their teens' health records if they agree to let them have a confidential relationship with their doctors.

Most hospitals or doctors make every effort to protect patients' privacy when it comes to sensitive information that's in their medical records. Sometimes a health care provider will feel that it's not in the best interest of the patient to release information to parents, even when a child is younger than 18.

For mental health records (such as the notes a therapist takes during counseling sessions) the age when parents no longer have access to a child's medical records is 15 or 16, depending on the state.

After you reach 18, your parents cannot see your records — by law. For some people, that may not be a problem. It may even seem like a good thing! But what if you have a health problem and need your parents to make decisions about your care if something happens? If you want your parents to have access to your records after 18, you'll need to sign a document authorizing them to do so, just as you would with anyone else.

Should I Keep My Own Medical Records?

It's a great idea. Many health care experts recommend that patients keep their own medical summaries or Personal Medical Records (PMRs). That way, they can bring them along on visits to specialists, new doctors, or even an unexpected trip to the emergency room.

Your PMR should include the following information:

• your name, date of birth, blood type, and emergency contact

• date of last physical exam

• dates and results of past tests and screenings

• major illnesses and surgeries, with dates

• any injuries you've had and/or illness for which you've been treated

• any allergies to foods, medications, household items, etc.

• a list of all your medicines, doses and how long you've been taking them

• chronic diseases, if any

• a history of illnesses in your family

• any accommodations you may need to make medical decisions (such as sign language interpreter, information written in large print, picture symbols, etc.)

Once you compile your PMR, you can keep it up to date by requesting test results and other medical records as they come up in the future. If you keep your PMR electronically, you can store a copy of it on a flash drive so it's always with you (if you do this, it's a good idea to password-protect it).

41