Medical Records 101

Why keep your own copy of your medical record

Maintaining your own copy of your medical record:

• Is the most effective way to insure that you will have access to all your medical information when you want it.
• It is the best way to assure that your records are complete.
• Provides a complete record you can take with you if you have to go to an emergency room.
• Recognizes that with a serious illness, you are likely to see a variety of doctors. Keeping a copy of your medical records allows you to see a new doctor without delay while that doctor waits to receive a copy of your records (which may be incomplete).

What should be in your copy of your medical record

Your copy of your medical records should at least include:

• An up-to date list of medications. 
  
  • You should also carry a copy of this list in your wallet or handbag at all times. 
  • To see what a list should contain, see List of Medications.
• Your own notes about: 
  • Each office visit with doctors and complementary therapists (with date and summary of what happened or was reported)
  • Treatments (including date and description), and
  • Laboratory Tests (including date and results)
• All reports about any operations
• Discharge summaries and any significant tests from hospital visits.
• Ideally, also include notes about when next exams or tests are scheduled. 

Where To Keep Your Copy Of Your Medical Records

Where to keep your records depends on what is most comfortable for you. Alternatives include:

• A simple file folder 
• In a box. 
• In a binder. The Lance Armstrong Foundation provides a free binder including space for your documents. See: www.laf.org.
• Online. You can keep a set of your medical records on line through such services as Microsoft's HealthVault  or a more basic site such as Google's www.Google.com/health . 
• Creating your own electronic copy. Rather than carry around a pile of documents, you can scan documents into your computer. When you get ready to go to a doctor, you can download the file through your USB port onto a portable file or stick. Any doctor you see can upload the documents into his or her computer.

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