When a person keeps track of their own medical information it is referred to as a PHR (personal health record)
A PHR brings together all of your medical information from different doctors, hospitals, pharmacies and clinics and store that information in one location that is easy to access and update.
When creating a PHR there are some things to keep in mind.
It should be created in a way that is easy to access and edit.
You should be able to bring it with you to any medical appointments.
The information should be stored securely as it will contain personal information.
It should be easy to share with others so that care givers and family members can access the information if necessary.
How should you store your PHR information?
In the past all of this information would have been stored in some kind of notebook or binder. This is still a good option because it acts as a backup copy to your digital records, and you can easily take the binder with you to medical appointments.
But you want to create a digital storage system as well. This can be done a few different ways. There are apps and websites that you can use to record this information but then you are depending on someone else to host your data. And most of the quality apps and programs cost money.
Another problem with websites and apps is they can be shut down or discontinued. When that happens, you could lose access to your information. Store your PHR on your computer, this gives you complete control of your information. From there you can upload the data to your cloud account. This will act as a backup and allow you to access the information when you are away from home.
You can then print copies of your digital information to create a binder.
Ensure that you have a backup plan in place for your computer so that all the data you collect is backed up regularly.
How to begin
It will take some time to get everything collected and organized. But once that is done you will only need to update the information on a regular basis.
Create a folder on your computer where you will store all of the information. I suggest creating a folder within your documents folder. This allows for easy access and backups. You should have a regular backup plan in place for your computer and your smartphone.
Go online to the medical establishments you visit. Many now have a patient portal. Register for access and use a password manager like KeePass to save and organize your login information. Once you have registered for online access you can log into each site and download copies of your medical records. If there is no patient portal look for the “contact us” page on their website. You may find information on how to request medical records there. If you don’t see that option, call them on the phone to make your request. They may require a written request to release your information. Some establishments will provide a form for you to fill out, or you may need to visit them in person. You may also be required to pay a fee for copies of your records. Moving forward anytime you have an appointment ask for copies of your records at that time. You might be required to sign a release form to obtain the copies. When you receive printed copies of your records scan them all to your computer and save them in the appropriate folder. You can do this using a scanner connected to your computer or using your smartphone.
If you are an active-duty military member, veteran or on Medicare you can access your medical records online.
Active-duty military service members
Veterans
Medicare recipients
Check for errors
Once you have received copies of your medical records check them for errors. A surprising number of medical records have been found to contain inaccurate information. If you find problems, you have the right to request the errors are corrected. The Health Insurance Portability and Accountability Act (HIPAA) guarantees that your medical records are private. This law also allows you to request corrections to your medical records. If you do find errors, contact the provider to request the corrections. Some minor errors can be corrected by calling the provider. For other mistakes you may need to make a copy of the pages that contain the errors and send that to the medical provider.
What medical records should you collect?
Laboratory and blood test results.
Surgical procedures.
Radiology and imaging results. These can include cat scans, MRI’s, mammograms, x-rays and ultrasound reports.
Other medical diagnostic reports. These might include EKGs, biopsy results, stress test results and so on.
Hospital and emergency room visit reports. This can include the doctor’s notes, test results, any procedures you have had done and discharge instructions.
Vision and dental records.
Doctor visit notes. These are the notes written by a doctor or other health care provider during your visit. Request a copy at the time of service. You can also request copies of notes from past visits.
A history of any counseling you have received.
Advance care planning documents. This could include living wills, organ doner authorizations, advance directives, DNRs, and/or POLST (Physician Orders for Life-Sustaining Treatment) forms.
Make lists
You can use any program to create your lists, but a spreadsheet program works well. Everything can be kept in one workbook and organized into individual spreadsheets. You can then save a copy of the workbook to your cloud account so that it is easily accessible on your smartphone. Print the list as well and add it to your binder.
Your Personal Information
Your name, address, phone number, email address, date of birth, gender, eye color, hair color, birthmarks and scars, height, weight, spouse or significant others name and any other personal information you would like to include.
Doctors and Medical Establishments
A list of doctors, hospitals, pharmacies, and other medical establishments you use. The list should include the name of the doctor and clinic, the address and phone number, what medical condition you see them for, and any other information related to that provider.
Medications
List all the medications you have been prescribed. The name of the medication, the prescriber, the pharmacy, the dosage, and anything else of importance. The list should also include any over the counter medications and dietary supplements.
Immunization Status
Document any immunizations you have had. The name of the vaccine and the date you received it.
Health Conditions
Document all of your current and past health conditions. Include when you were diagnosed, what doctor or medical clinic made the diagnosis, what tests and procedures you have had done and the date of each and any allergies you may have.
Blood Type
List your blood type. If you are not sure what your blood type is call your primary care physician to find out.
Support Providers
List of support providers and services. This could include nursing home or eldercare services, in home health care providers, patient advocates or navigators, therapy services and others who have helped manage your care.
Emergency Contacts
List the name, address, phone number, email address and relationship of any emergency contacts.
Health Insurance Information
The name of your insurance company, address, phone number, web address, policy, group and ID numbers, employer, and any other relevant information.
Family Medical History
It is useful to document as much of your family medical history as possible. Especially for close relatives like your parents, siblings, aunts and uncles and cousins. Many doctor’s offices ask for this information. Take the time to question relatives that are still living and do your best to recall any medical conditions of relatives that have passed away.
Lifestyle
Notes about your lifestyle such as smoking, drinking, sleeping, exercise routines and your diet.
Having an up-to-date PHR will improve the safety and efficiency of the health care you receive. This is especially important when you are working with multiple health care providers. Having all of your records in one, easily accessible location will save you time by ensuring that you can refer to this information quickly when necessary.
If you require support from a caregiver now or in the future the PHR will be helpful to them as well.
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