Previous columns explained how getting a copy of your medical records can make a difference in the tests and treatments you get, in your costs for health care, and ultimately, in your health and well being. Also discussed was how to decide what medical records to get and how to get them. This column explains what to do with your records once you have them.
Some doctors get nervous when people start reading their medical records. They are afraid that patients will be confused, angry, or upset by what they read. One of the classic concerns doctors have is that the many acronyms they use will be misinterpreted. For example, if the doctor’s notes say that you are “SOB,” that’s not an insult. It’s an abbreviation for Short of Breath. It may help if you start with the assumption that your doctor is a professional who is simply doing her job, and that any notes in her records about you reflect this fact.
You may want to invest in a pad of sticky notes before you sit down to read your medical records, so that you can make notes without marking up your official copy of the record. You may later want to give other doctors a copy of some of the records, and you might prefer that they not have your added questions or commentary on them. Even if you don’t care if they see your notes, they may want to see the documents exactly as the doctor provided them.
If you are attempting to unravel a medical mystery, you may find it useful to take careful note of anything in the record that you didn’t already know or that doesn’t seem to match the facts that you do know. If the language is confusing, seek help either by looking up terms on a reputable site on the internet, or by asking a friend with medical knowledge to help you translate.
If your medical situation is complicated and you have collected a lot of records, you might find it useful to create a summary of the records which would include, in chronological order:
- Doctor, hospital, lab, or other site or provider contacted
- Reason for the contact: for example, to report certain symptoms
- Tests you were given and the results of the tests
- Diagnoses you received
- Treatments you were given
At first glance, it may not be obvious what diagnoses you have been given. If you see DX or DX1, DX2, and so forth followed by a number that has three digits with up to two decimal places, then the doctor has written a standard code for your diagnosis rather than using words. To find out what the numbers mean, go to http://www.icd9data.com/2011/Volume1/default.htm and type into the search box the numbers you found in your records, for example, 493 or 493.82. (These are both codes for asthma.) Ignore the ads on the site, which highlight scary medical problems right under the definition of the code number you have typed in. Note that doctors may sometimes write down two or more diagnostic codes, and it’s important to capture all of them.
Even complicated medical situations can often be summarized in just a few pages using the above approach. It can be very helpful to take such a summary with you to give to the next new doctor you see.
Once you have combed through your records for surprises and have prepared a summary of your medical history, you might start to put together a list of questions to ask your doctor and/or a list of other action steps to take. For example, you might realize that you never heard back about one or more of the tests that you were given recently, and you might seek that information. You might realize that you are still taking a drug to treat a condition that you no longer have, and decide that you want to bring this point up to your doctor. You may find that critical steps needed to follow up on your care are noted in the doctor’s records -- but that you had never heard of some of them, and some of the follow-ups never happened.
After reviewing your records, you might find it useful to organize them for filing. If you plan to keep your records on paper, consider using three-ring binders with tab dividers. You might set up sections for major health events (“Heart Surgery, 2011” or “Broken Leg, 2010”) or for providers (“Dr. Black, 2008-2010,” or “St. Mary’s Hospital, 2011.”) If you have more than 20-30 pages behind one binder tab, it will be easier for you to find relevant information later if you divide the documents out into separate sections (“Blood Tests, 2010,” or “Dr. Black’s Notes, 2011.”)
If you want to computerize, decide whether you simply want to scan the documents and create computer folders that are the equivalent of the paper tabs described above, or if you want to keep a more elaborate computerized PHR (Personal Health Record). For more information about keeping a PHR, one resource is www.myphr.com.
A future column will explain how to correct errors you find in your medical records.