Patient: “Doctor, it hurts when I do this.” Doctor: “Then don’t do that!”
Are your medical records pretty meager? Maybe you’ve kept up with your children’s immunization records, and you might have copy of your recent contact lens prescription, but if your life depended on knowing how long ago you had a particular procedure or who performed it, how quickly could you access the information?
Continuing our discussion of the family/personal filing and however everything can fit into one of five categories, we’ve reached:
Financial
Legal
Medical
Household
Personal
Doctors tend not to share medical paperwork, records, X-rays unless patients request them, opting to safeguard the records themselves, so you might have a pretty slim collection. In fact, you might think that you don’t need to keep any medical records at all because you can always get copies from your doctor. Actually, there are good reasons to maintain your own records:
- You may need to access information in a hurry. (e.g., if your child’s summer camp calls to report a minor accident and wants to know how long ago your child’s last tetanus shot was.)
- The doctor’s staff may be unreachable on weekends and holidays.
- A change in insurance company may require you to provide detailed medical history information.
- You may be able to avoid unnecessary medical tests if you can show you’ve already been tested.
- Your doctor or dentist may retire before you have a chance to get copies of records.
- You don’t have a regular optometrist and can’t recall where you last got an eye exam. (Was it at the mall? You remember there were holiday crowds…)
- You vacation or work outside North America – you’ll often need proof of health and immunization for travel.
A little preventative organizing can literally save your life down the line. Start with these basics file sub-sections:
MEDICAL CONTACTS
Keep contact information for each medical professional each person in the family sees. Unless one family member sees a lot of specialists, a few sheets of paper tucked into a file in the front of the medical section usually suffices. In the tense moments of an emergency, you wouldn’t want to have to rely on your memory.
For each health care practitioner, include the name, address, phone and fax numbers, and email address. To get you started, collect information for:
- Internist/Family practitioner
- Gynecologist/obstetrician
- Dentist
- Optometrist/Ophthalmologist
- Specialists
- Alternative Care Practitioners (acupuncturist, herbalist, massage therapist)
Next, you want to create a hanging folder for each person in the family including at least these three folders for each specific area:
MEDICAL — include the following information:
- Immunization records – when was your last tetanus booster shot?
- Test Results (cholesterol and other blood test results with numbers, letters confirming results of mammograms, pap smears and bone density tests for women, prostate and other exams for men, etc.)
- Medical History – keep notes regarding any serious illnesses, accidents or surgeries, transfusions or procedures; Download this sample form to get you started.
- Pregnancy History – keep a copy of all test results and a simple log of any procedures
- Mental health – as with physical health, note any mental health problems, treatments and medications as well as the dates
- Medications
Sidebar on MEDICATION HISTORY
For most families, keeping a page in each individual’s “Medical” folder will be enough. However, if your family members take many prescriptions, you may wish to keep a separate folder to track all medications. Create a spreadsheet or online record where you can quickly update your prescriptions, and print a copy for your files in case you need to fax or quickly provide it to a physician or hospital.
Include each medication’s brand or generic name, dosage, frequency, prescriber (if applicable), purpose and date started. Include:
- Prescriptions (e.g., oral contraceptives, preventative and curative medicines and acute-care drugs like epi pens and migraine medicine)
- Dietary supplements – vitamins, minerals, beverages
- Herbal remedies – include those recommended by alternative care providers like acupuncturists as well as any you’ve picked up at health food stores
- Nonprescription medications — include aspirin-a-day therapies for preventing heart disease and stroke
DENTAL
Dental professionals vary in how much information they generally provide. If you don’t ever have a detailed dental treatment plan, don’t worry about this. However, if your doctor or orthodontist creates a treatment plan, keep it in this folder. Also, keep notes regarding when you’ve had dental X-rays and what procedures you’ve undergone. Dental health is closely tied to medical health, so a complete record is important.
VISION
If you often switch where you have eye exams, it’s essential to keep records of your prescriptions in order to gauge vision changes over time. Keep copies of your old eyeglass or contact prescriptions in this folder, in reverse chronological order.
The three categories (dental, medical, vision) usually suffice for most families. However, if anyone in the family has a specific, ongoing medical condition (allergies, arthritis, etc.) add extra manila folders to cover more extensive paperwork. For allergies, in particular, I suggest having one folder, with a page for each family member, noting whatever allergies they have to:
- Drugs
- Foods
- Animals
- Environmental/Chemical agents
- Other allergies
If you are single and in your twenties, your medical file may only include your immunization record and notes on occasional healthcare visits. However, starting your filing system early will make it much easier to know where to put notes as your medical history (and family) grows.
What if you don’t even have any medical records to even start this paperwork? I know, most of Paper Doll is about helping you get rid of excess paper, but this is one time you want to acquire paper.
One of your important legal rights under HIPAA (the Health Insurance Portability and Accountability Act) is the right to obtain copies of your medical records and to make sure the information within is accurate. HIPPA covers just about all medical records except your child’s K-12 school nurse records.
When you move or change doctors, or when your child goes off to college or starts his/her own filing system, use this letter template for requesting a copy of all your medical records, http://www.privacyrights.org/Letters/medical2.htm
Finally, if you have pets, keep veterinary medical records in hanging files just behind those of the human family members. Each pet needs just one file folder – you’re safe skipping special dental and vision files for pets.
To your health!
Next up: Household Papers
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