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Handling Medical Records

by Michael R. Wasserman, MD

People may not have total access to their medical record kept in the doctor’s office. But usually people own the medical information, and the doctor or institution owns the document itself. The courts can require submission of copies or summaries of the records, but only in certain specific legal situations that most people do not experience. When people request their medical record, a staff member at the doctor’s office usually copies and releases the record to them or creates a summary of all or part of the record to send to other health care practitioners. People who want a copy of their whole medical record for personal use may or may not be entitled to it, depending on state law. Generally, people need only the most useful medical information. They do not need a complete record, which may contain a lot of information that is not useful to them.

To make sure they have what they need, people should maintain a personal medical record of the most significant information. They should not rely on memory. Immunization records, which are traditionally kept for children, should be kept current throughout life. People should write or ask someone to write their drug regimen on one sheet of paper to keep with their medical record. They should also keep a copy of their drug regimen with them at all times in case they need emergency medical care. This information can be updated as the regimen changes. Copies of laboratory results should be included with the medical record for future reference. People may also want to keep a diary of their symptoms with their medical record. Computer software and Internet programs are available to record most medical information, or a file box or binder may be used.

Keeping a copy of their medical record helps people participate in their health care. For example, it helps them better explain a problem to a health care practitioner.

Confidentiality laws and ethical principles protect the privacy of communication between people and their doctor. These laws also protect the contents of the medical record that is maintained by a doctor or hospital. One such law is the Health Insurance Portability and Accountability Act (HIPAA—see Confidentiality and HIPAA) of 1996. HIPAA states that disclosing a person’s medical information normally requires the person’s written consent. In the doctor’s waiting room, people are asked to sign a form confirming that they are aware of HIPAA and their privacy rights. The form also states how their medical information can be used and shared. HIPAA allows medical information to be shared in certain specified cases. For example, it can be shared

  • To coordinate and facilitate a person’s treatment (especially important when different practitioners and health care facilities are involved)

  • To enable doctors, other practitioners, and hospitals to be paid for health care

Thus, information needed to authorize payment may be shared with managed care organizations and health insurance providers, who may require medical information as a condition of payment for a claim. Sharing this information also requires the person’s consent, which is usually obtained before health care is provided. A person’s medical information cannot be shared with the person’s employer or marketeers unless the person gives written consent.

Increasingly, health care practitioners are recording and storing medical records electronically. This practice has the potential to enable different practitioners who care for the same person to share information about the person more easily and with fewer errors.

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