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Published: January, 2007; Vol 3, Num 8

 

What’s the Status of Your Personal Medical File?

More than likely, you don’t even have one. But you should.

A personal medical file is the place where you gather and keep information that pertains to your health. It includes:

  • A record of your doctor visits, diagnoses and medical treatments
  • The list of your current medications
  • Your personal family medical history

As modern society in the U.S. and Canada becomes less settled and more transitory, our health care goes through changes as well. Just a generation ago, a patient might use the same family physician for most of his or her life. In today’s mobile society, doctors and patients are both likely to move several times during a lifetime. With each move, a new doctor-patient relationship must be established.

In both countries, it is the responsibility of the physician to maintain a record of a patient’s problems and treatments. Generally, these records, though owned by the doctor, are the embodiment of private information shared by the patient with the doctor. Thus, patients retain the right to access and copy their records and to the protection of their confidentiality.

That said, however, many situations arise in which it is difficult to track down and secure copies of one’s records. Thus, despite generations of past practice, it makes sense for each person to maintain their own personal medical file. What should go in the file?

First is a running chronology of your health. While a simple record of each doctor visit will probably cover the highlights, you might also keep notes of certain problems as they develop or as they resolve themselves. Notes on a doctor visit should include the date, the doctor’s name and contact information, any diagnosis and any recommended treatment or other advice. Also, the results of tests should be included or noted. If you don’t keep a record elsewhere, you might also include the cost of your visit and treatment (while the cost of medical care can become a tax deduction if your incur significant medical expenses during a given year, most people with routine care will not spend enough to reach the annual, minimum threshold for a tax deduction).

Second is a list of your current medications. If you keep a chronology of your health history, you will also be keeping a record of your medications. However, it is important to have a current list on your person (or in your wallet or purse) so that it can be found and used in emergency situations. Some medications work at cross purposes; some are dangerous in combination with certain others. If an accident renders you unconscious or simply incapacitated by its shock or trauma, a list of currently-used medications could prevent a worse disaster.

Third is a family medical history (see The Apple Doesn’t Fall Far from the Tree). Because so many health problems are linked to hereditary factors, you will be much better prepared to discuss your health status, risks and treatments with your physician if you know the history of illness and disease in your family. For most of us, it is necessary to construct a family medical history by systematically gathering health information from or about our parents, grandparents, brothers, sisters and children. Recognizing the importance of this effort, the U.S. Department of Health and Human Services has established an online tool to facilitate your work.

Starting a personal medical file is as simple as finding a place on your computer or in your file cabinet to keep the information and making a first entry. The American Health Information Management Association provides a list of record management options. Afterwards, add new information whenever you have significant health concerns or consult with your doctor. Also, get an index card, write down all of your medications (including regularly used over-the-counter drugs) and store the card in your wallet. Finally, go online and begin creating your family history, calling your relatives to retrieve missing information.

It’s a new year. This is a good time take more control over your own health management. If you don’t do it now, you may not be able to obtain the information when you need it.