Last week, I had a consultation call with an impressive young woman. Despite her various serious health issues that have left her basically housebound, she had a positive attitude. She told me talking to and understanding her doctors had been a big part of her challenge. I then learned that she had no idea she could review her medical records and care plans. I thought it would help her understand her doctors' views and allow her to prepare for better office visits.
Collecting and reviewing medical records is what I regularly do as I begin my work with a new client. But her current financial means are limited, and I wanted to see if I could help her with a minimum fee. I asked her if she would be willing to try obtaining copies of her records by herself. She said yes, so I briefly explained the process on the phone.
But I knew she would need a reminder. I also knew the process varies by the institution and is often frustrating. I checked if any suitable instructions were available on the Internet to share with her. Various resources are available, but none seems particularly helpful for patients like her (people with limited knowledge about the medical record). Either their information was lacking, or it contained too much information. For example, this is a pretty informative site but may be overwhelming due to the sheer volume of information.
If I have difficulty finding good information for the patients like her, I realize those patients wouldn't find any! Hence, I decided to write a blog explaining why this task is crucial for them and the process of obtaining their records, hopefully without too much pain!
1. What is the Medical Record, and why is it crucial for patients?
First, what exactly is the medical record? Many patients may find it confusing, just like many other things in healthcare. Some healthcare professionals might call it by different names, the health record, protected health information, doctor's note, or medical chart. But essentially, we're talking about an official document that medical professionals regard highly valuable but don't readily share with their patients. The medical record is a collection of legal descriptions of medical encounters of ONE PATIENT, written by ONE PROVIDER (often a doctor), and organized by the date of the encounter. It also includes supporting information (lab results, diagnostic tests, etc.). A medical facility (or, more recently, a network of facilities) maintains it.
Despite their hidden nature, every patient should take medical records seriously. That's because they are the primary vehicle for all kinds of medical, insurance, and legal professionals to form an opinion on you and make important decisions about you. For example, all of your doctors record their thoughts about your condition and any care provided. Your new doctors may read these notes as they consider the appropriate action for you. Insurance companies could also use those records to decide whether your care should be covered. Hence, errors/omissions (unfortunately, this happens often!) in your records can make you take unnecessary tests and procedures or give your new doctors a wrong impression of you. Or inaccuracies in the record (e.g., allergy, medication, history) may even put you in danger, as well as insurance denials.
As a patient advocate, I can't stress enough the benefits of having accurate medical records readily available 1) for treatment options and any future medical events and 2) to save time and money. Even though the facility created those documents, patients must know that they ARE ENTITLED TO ACCESS ALL PARTS OF THEIR MEDICAL RECORDS.
2. A quick breakdown of medical records (you can read this section after obtaining your record)
Unfortunately, the way medical institutions organize their records isn't the same. They may also use various terminologies, but you don't have to understand everything! The most significant part of the medical record you should pay attention to is the (physician's) 'note' or the 'progress note.'
Below is a brief description of how "notes" are usually organized. I hope it gives you a framework to understand the doctor's note. Inside, you should find these parts (wording may vary):
Date and patient's demographic information.
Subjective: A brief story of the patient based on what s/he told the provider and the chief complaint (the reason for seeing the provider).
Objective: The findings from the physical examination, lab tests, imagining, etc.
Assessment: This is where the provider labels the problem the patient's experiencing → a diagnosis (But in reality, the provider may not provide a diagnosis.)
Plan: What's the next step for the patient. This may include additional tests or the direction the patient should follow.
The provider's name and (electronic) signature.
3. The process of obtaining a copy of your medical record
A) The quickest way (if you have access to a patient portal that complies with the current law)
First, log in to your patient portal account and look around for the doctor's notes (often under the "visits" section). That's because, as of April 2021, "all U.S. healthcare systems are supposed to electronically share clinicians' visit notes with patients at no charge," thanks to the passing of the 21st Century Cures Act https://www.healthit.gov/curesrule/what-it-means-for-me/patients )! Unfortunately (as you probably guessed), not all facilities and doctors have fully complied with this law as of writing this article. (Reporting these incidents to the authority will be a topic of the following blogs!) but proceed with B) if you cannot find any notes in the portal.
B) The usual way to request the medical record - Through the designated department/person
First, a word of advice: You may need patience and perseverance in this process. The staff members or institutions may tell you different policies. You might want to (politely hang up the phone and) speak to another employee if one staff member gives you a hard time. Big hospitals and affiliated doctor's offices will likely require you to use their own form. The staff can provide you with the form in the office (or you should also be able to obtain it online and print it out). You can request the information sent to yourself, your family, or your advocate.
B1) On the form, the information they require is in general:
- Patient's full name
- Patient's date of birth
- The date range of the records needed
- Whether you want paper or digital copies
- Where to send the records
- Patient's signature and date
- If the form asks why you need your record – You can say, "At my request"
Some forms may ask more questions. If unclear, just ask them how to answer these questions.
B2) Unless you fill out the form at their office in person, you will have to scan it, then email or fax it (yes, they still use fax!). After submitting the form, you should wait for several days (unless you get lucky and receive your record by then), then call the office. This step is vital (because you may not get any response unless you follow up within a reasonable timeframe). In my experience, I always tell them that I want to make sure they've received my request in a friendly way. Frequently, they work on my request right away and send the records to me on the same day.
C) A method that's worth trying right after every important doctor's visit or imaging study
I highly recommend this method because of the potential hassle of sending your request in and following up (as described above). Before leaving the office after your medical appointment, you should simply ask the staff for your record. They may or may not ask you to fill out the form. The key here is to clarify that you're NOT talking about the 'visit summary' (the skimpier version of the medical record). You want the actual note related to the visit you just had. (They may also ask why you want it, as they aren't used to patients asking for it. If so, you can simply tell them you decided to pay better attention to your health, etc.)
Because they already know you are the patient, this method can be much quicker. If they tell you the note isn't ready yet, ask them to mail it to you when it's written. (You may still have to follow up if you don't receive your record within ten days or so.)
Personally, I find this method highly effective right after an imaging study. The technician can usually make a copy of your images onto a CD within a few minutes and give it to you!
Okay, here you have it.
As you continue to collect your medical records, promptly organizing them is just as essential as obtaining the records. So you can access the right information quickly. But that's a topic for later writing!