If you’re like most people, you probably keep track of your store receipts along with other important documents like purchase invoices or your car’s service records, just in case.
But what about your medical and health records? Are you keeping track of those?
Probably not, said Mark Laudenberger, director of health information management at Middlesex Hospital in Middletown.
“Most people don’t think of it,” Laudenberger said. “When people have health problems they begin to think about this all the time, but when they are in good health they are less interested in obtaining copies of lab reports and things like that.”
It’s not because consumers are unconcerned with their health history. Instead, it’s that most of them assume their physicians have all their records stored away indefinitely for safekeeping.
Though it’s possible they do, it might be surprising to learn that Connecticut state law requires physicians to hang on to medical records for only seven years. After that the records can be tossed out, without patient notification, unless the physician’s practice is closing.
For hospitals and long-term care facilities, the term is 10 years. Other records like lab results and X-rays must be retained for only five and three years, respectively.
“In general,” said Laudenberger, “the approach is that every organization has a minimum limit to how long, by policy, they’re required to keep medical records. What surprises patients is that policy isn’t really well known when they go back for them.”
While many medical practices and facilities retain them for much longer, including Middlesex Hospital, which has records dating back to the early 1900s, they don’t have to.
So patients attempting to locate their past medical records prompted by health or other concerns may discover that, depending on how long it’s been, the documents no longer exist.
“The perspective of the consumer is that it lives with your doctor, therefore you don’t need to necessarily keep track of it,” said Dr. Kiki Nissen, physician and associate dean for Graduate Medical Education and Faculty Affairs at UConn Health in Farmington.
But you should keep track, for any number of reasons.
“Medical records are not always accurate,” she said. “In reviewing medical records on patients transferring care, it’s clear to me when I ask a patient about a particular problem, there’s a very different picture than what’s been written down.”
And, contrary to what patients might believe, according to Nissen, not everything they tell their doctor is entered or documented in their records. With significant details potentially lost in translation, it’s important to be aware of what’s been logged and what hasn’t.
“Health history is critical to me as a physician. It gives you clues into diagnoses that are sometimes challenging,” Nissen said, and went on to explain that having an accurate health history becomes even more important as we age.
“Recording your life story from a health perspective is very critical as you get older because we forget things and we rely on health care professionals to have it documented somewhere, and that will be passed on to the next provider.”
Yet another reason to verify what’s in your medical records is that physicians, like anyone else, are human and occasionally record things incorrectly. “Doctors make mistakes; we record errors. For this relationship to exist and be perfect,” Nissen said, “both members need to contribute.”
Part of a patient’s contribution is looking over their records and fact-checking to ensure that what’s documented is correct and up-to-date. And it also affords patients the opportunity to ask any questions about what’s in their records or clear up any confusion.
Fortunately, as technology advances, that exchange of information is becoming more precise. Many doctors now use computers to access and update health records, which are accessible to patients through electronic portals.
To view them, patients must have access to a computer. If not, most physicians send their patients home with a paper summary of their visit, identifying the issues discussed, the medications prescribed and other important information. If not, patients can ask for one at the end of the appointment.
Dr. Sherry Banack, a pediatrician practicing in Wethersfield, offers patients and their parents the ability to view records of their children’s medical history through an electronic portal. She also sends home a paper summary after each visit and said that hanging on to them isn’t a bad idea, especially if the child has any type of ongoing medical or psychological issues.
“It’s important if there’s any type of chronic illness.” she said, “You should keep records as a parent.”
Banack also said that it’s good to have them just to track other important information like vaccinations, growth and medications. “I tell a lot of new parents, ‘I’m going to give you one of these summaries at each physical, it’s not a bad idea to keep them in a binder, to keep track.'”
Whether they’re yours or your child’s, Laudenberger suggests keeping any summaries given at the end of a medical visit as a way of monitoring your history and to use as reference in the event of a health concern.
“I think it’s good to keep records of your lab results,” he said, “good to keep records of your office visits, physicals in particular, as it may relate to your blood pressure or any particular medical issues that might be happening.
“Should a chronic disease develop at some point in your life, it would be useful to have a file of your significant results on hand so you have something to refer to if you were trying to learn more about your disease.”
And, he said, it’s also not a bad idea to bring those records with you to office or specialist visits to have results and other important information readily available if needed.
“One of the most challenging parts of a physician’s role is to ensure they have a complete picture of their patient. Any information that is available to them, whether it be in the form of the patient’s or another provider’s records, is extremely helpful to any physician in their work-up or treatment of a patient.”
Fortunately, it’s never too late to start keeping track, and for those who want to obtain past medical records, many physician’s offices, hospitals and other facilities will provide them if the request is made in writing. There’s typically a fee of 39 to 65 cents per page.
Regardless of how you track and preserve your records, it’s essential that you do in order to understand and validate your health history, said Nissen.
“It’s your story,” she said. “It’s critically important.”
Link to Original
Sarah Lemire 