Handling medical records

[Jason Yan]

People may not have total access to their medical record kept electronically or as paper files in the doctor’s office. But usually people own the medical information, and the doctor or institution owns the file itself. The courts can require submission of copies or summaries of the records, but only in certain specific legal situations that most people do not experience. When people request their medical record, a staff member at the doctor’s office usually releases the record to them or creates a summary of all or part of the record to send to other health care practitioners. People who want a copy of their whole medical record for personal use may or may not be entitled to it, depending on state law. Generally, people need only the most useful medical information. They do not need a complete record, which may contain a lot of information that is not useful to them. (See also Introduction to Making the Most of Health Care.)
To make sure they always have what they need, people should maintain a personal medical record of the most significant information. They should not rely on memory. Immunization records, which are traditionally kept for children, should be kept current throughout life. People should write or ask someone to write their drug regimen on one sheet of paper to keep with their medical record. They should also keep a copy of their drug regimen with them at all times in case they need emergency medical care. This information can be updated as the regimen changes. Copies of laboratory results should be included with the medical record for future reference. People may also want to keep a diary of their symptoms with their medical record. Computer software and Internet programs are available to record most medical information, or a file box or binder may be used. Additionally, many doctors