Medical Records Empower Patients

by francine Hardaway on October 5, 2010

Yesterday i went to my primary care doctor. The P.A. said,  as she looked at my records,  “you haven’t been here in a while.” I agreed, and the next thing she said was “we have to send you for blood work.”  Here, Ididn’t agree. i had blood work in May as part of a visit to another doctor, to whom my primary care doc  referred me.

But she didn’t have the results. His office never send them to the referring physician.  And neither did the lab, despite the fact that I have been a patient of both the physician and the lab for ten years.

Thankfully, I had them myself. I hauled out my trusty iPad, got on the office’s (unsecured) wireless network, and retrieved them from Google Health, where I participate in an online pilot program to give patients access to their own records. My insurance company, the pharmacy and the lab upload my results for me.  I was able to prove the date of the tests and share the results, saving  myself some time and the system some money.

That’s the least significant example of why patients need their own records I can think of. Many other examples involve life and death. Patrick Malone, a leading patient safety advocate, writes a newsletter on health affairs, and I’ve lifted this from his latest issue.

Having your  own medical records is an essential first step to becoming an informed, proactive patient.  It accomplishes a bunch of things all at once.

You become literate in your own body.  You learn the lingo your doctors use and you remind yourself of the concerns your doctors have about you that you might rather not think about.

You learn a lot about your doctor. Does he or she have an organized set of records? Do they record what you told them in your sessions with reasonable accuracy and completeness? If the answers are no, you might want to think about getting another doctor.

You can correct errors. Do your records say something about you that’s just plain wrong? Or do they leave out something important, like an allergy to a common drug such as penicillin? Now is your chance to fix things before they have bad consequences.

You can prevent potentially huge failures in communication.  People find abnormal test results in their own records with distressing frequency — but usually they don’t look until it’s too late.  There are so many test results getting filed into medical records and so many opportunities for miscommunication that you can never assume no news is good news when the doctor’s office has failed to tell you about a test result.

You should especially get a copy of every lab report, X-ray study and specialist’s report.  The easiest way is to start asking for these routinely, up front, when you’re about to have the test done. But if you’ve got any kind of complex medical history, go ahead and ask your primary doctor’s office for a copy of your entire chart.

How do you do it?

Just ask.  Put it in writing.  You have a legal right to your records in all 50 states.  Remember, it’s your body, and you can save a life, maybe your own, by reading your own records.

Unfortunately, it’s not that simple. Although you do have a legal right, according to the law in my state, the lab only has to provide the results to the person who authorized the test. This does put a great deal of power in the hands of that primary care doctor. Make sure you have a good one, and that she cooperates with your desire to have and read your own records. As all these practices go online with medical records during the next few years  (my own doctor is doing it now), this should be easier. But as Malone points out, you have to READ your records, too, because often it is still garbage in, garbage out.

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October 5, 2010 at 5:41 pm

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Patrick Malone April 26, 2011 at 6:37 pm

Thanks for sharing my newsletter on getting and reading your own medical records. Just one small correction: I do not agree that a lab doesn’t have to give you a copy of your own test result. Yes, they will often tell you that. they only give it to the provider who ordered the test But if you persist, and if you threaten to complain to the U.S. Justice Department for a HIPAA violation, they should relent. Patrick Malone

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