Obtaining Medical Records
As an adult congenital heart disease patient or a caregiver for a child with congenital heart disease, you will likely be asked at some point to obtain patient medical records from one physician and provide them to another physician. This allows the new medical provider to review the diagnostic and treatment history for you or your child, preventing duplicate or unnecessary tests and showing the new provider relevant medical information. Furnishing a copy of medical records will also be necessary when seeking a second opinion.
In the United States, your legal right to view and request your records is governed by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA’s Privacy Rule outlines appropriate sharing of your protected health information (PHI), such as between medical professionals and insurers or with other medical staff or contractors with insurance companies or hospitals. What this means for obtaining your medical records is that you will be required to authorize that a copy of your records be sent to the new physician who requested them. A good resource for information about medical records and HIPAA is the U.S. Department of Health and Human Services (HHS) website at http://www.hhs.gov/.
The process for obtaining your records can vary slightly depending on the medical provider, but in general, you can follow these steps to have your records sent to a treating medical professional. These basic steps apply to sharing of both paper and electronic health records (EHRs). Please note that HIPAA does not give you the right to access notes from treatment by a psychotherapist, and the rules for sending those notes to other providers differ.
To obtain your medical records:
- Contact the physician’s office or hospital at which you were treated to find out their process for requesting your medical records. In some cases, you will be asked to submit a signed letter. Ask the office about any requirements for the format of the letter. In other cases, the medical center will have a form available to you to fill out. These forms can sometimes be downloaded from the provider’s website and printed.
- Be sure to indicate on the form or in the letter whether your records should be sent to another provider’s office or if they should be sent to you. Provide detailed, accurate address information for the recipient of the medical records. If you are sending the records to another provider, contact that provider’s office to find out the exact address and who should be listed as the recipient. In addition, you should follow up with the recipient provider to ensure that all pertinent information has been properly sent.
- Ask the provider from whom you are requesting the medical records about any fees that you will need to pay. By law, providers are allowed to charge you a reasonable fee for copying and sending the medical records (though not for retrieving the records).
- If you have the medical records delivered to your home or office, before giving those records to your new provider, photocopy the records and keep a copy in your home files for future reference.
Keeping a Personal Health Record (PHR) at Home
One step you can take to feel more in control of your health care or that of your child is to maintain a personal health record (PHR). This is simply a term for a record that you maintain on your own, versus a medical record that is maintained at your medical provider’s office. A PHR allows you quick access to your medical information in case of an emergency or if you need to supply past health information to a new provider.
You can keep your personal health record in whatever format is easiest for you: as a paper file, using software on your computer, or by using a web-based platform. If you choose to use a web-based platform, be sure to read the privacy practices carefully and be sure you feel comfortable with both the privacy statement and the security of the website.
Each format has advantages and disadvantages:
- Paper file. Request a copy of your medical records from your physician (see the guidelines above) and put these records in a binder, file folder, or other container. You may wish to keep this file in a firebox alongside other important papers. Keep notes of any medications you have taken or are taking and when. Also note tests you have had performed and any immunizations and allergies. A paper file gives you complete control over your health information, but you can only access that information if you have the file with you.
- Software. Choose a computer program that has the features that appeal most to you. Keep notes about your doctor’s visits, diagnostic tests, surgeries and procedures, family history, immunizations, and any allergies. Software may make it easier for you to organize your information. Be sure to create back-up copies of the electronic file, or periodically print out your health information and store it in a secure location, in the event that your computer crashes and the information is lost.
Questions to Ask Your Doctor About Medical Records
- Which medical records do you need from me?
- Who (hospital social worker, etc.) can help me with requesting my medical records or those of my child?
- What is the process for having medical records from another provider sent to you?
- How do I have medical records from treatment with you sent to another provider?