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Maintaining Accurate Personal Medical Records

Get tips on Maintaining Accurate Personal Medical Records and California Health Insurance Quotes

Many people are unaware that it is their right to ask for and receive a copy of any medical record he or she asks for. Medical records may contain everything from your social history to immunization records to x-ray reports, lab work reports, physical exam notes, surgery, and rehabilitative therapy reports. As long as it’s contained in your medical record, you have a right to access such information. As a matter of fact, California health insurance providers suggest that individuals keep and maintain copies of their medical records whenever possible.

While most physician and other healthcare providers and health clearinghouse providers may charge a small (it must be reasonable) fee for copying a medical file or records, they are required by law and HIPAA (Health Insurance Portability and Privacy Act) to do so. In most situations, a verbal request at your physician's office will suffice, but if not, and for others, you may need to make the request in writing. For medical care received in a federal facility (and covered under the 1974 Federal Privacy Act), you will have to make your request in writing.

In order to maintain accurate personal medical records, it’s best to follow a step-by-step procedure that will help keep you organized. Here's one suggestion:

  • Purchase a separate folder file, plastic container, or notebook binders to store your files.
  • Organize your files according to your own preferences. For example:

    Lab test results

    X-ray reports

    Doctors office visit reports

    Dental visits and reports

    Vision exams and reports

    Immunizations (for school, work, or travel)

  • Organize your files by date, with the most recent at the top or front of your file.

Individuals who rarely visit the doctor may prefer to file medical records by medical incident. For example, let's say you visited your doctor for a nagging cough in late January and your physician performed an examination, asked for blood work, and scheduled you for a chest x-ray, the results of which were available to you in early February. In such a case, it might be more organized to group the results of these tests and visits together even though activities may be spread over a couple of months.

For individuals dealing with repeat visits, chronic illnesses or disease processes that require routine visits, laboratory tests, or x-rays, it would be more organized to file such records by the services performed. For example:

  • January

    Lab tests

    Doctor’s office visit – (if you have more than one doctor, create a separate file for each one with tests and results for each one filed in a separate folder).

It's not so important as to what type of filing system you devise to keep your medical records organized, as it is to ensure information contained within them is accurate and up-to-date. California health insurance agents and medical providers encourage individuals to take a more active part in their healthcare by always reviewing his or her records, and asking questions or requesting changes in basic information when necessary.

If you see an error in any personal or background information contained in a report, or any part of your medical record, notify your healthcare provider immediately. An addition or amendment will be placed in your medical file with the corrected information noted.

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