Personal Medical Records

You Need to Have on Hand

You may think that getting personal medical records is difficult, but it is not.

And it is not difficult to obtain your elderly loved one's records either. You just need to know how to do it.

Your medical records, in paper form or in the form of online medical records, are YOURS. They do not belong to the doctor, hospital or lab.

The HIPPA Act, the one you sign on when you visit a new doctor, lab or pharmacy, states exactly that.

But when HIPPA first came out and education was completed for everyone in the health care field, it sometimes wasn't clear to employees that the only person who has the right to those records without your consent is YOU.

You will have to sign a release at every facility or company and if you are obtaining personal medical records for your elderly loved one, they will have to sign a release as well. Once that release is on file, you should have no problem getting a hard copy of all of their records.

Now that you can get them ...
Which ones do you need?

I would recommend using a file system that is enclosed, like the ones to the right, for each individual family member.

Label the dividers clearly and make sure to take it to all doctor's appointments to update the information at the time changes are made.

Use a separate folder for each elderly person you are responsible for and include all of their personal medical record.

Important information to have includes:

  • Personal Information: This includes full name, date of birth and social security numbers.

  • Insurance Information: Copy of their medicare/medicaid information and any supplemental or private insurance they may have. A copy of the front and the back of the card is what we would need to verify insurance coverage.

  • Diagnosis List: Include the diagnosis, such as Asthma, Diabetes, Congestive Heart Failure, along with the year the diagnosis was made and who the treating physician is for that particular diagnosis.

  • Physician Information: You should have the name, address and telephone number of all of their doctors, including specialists. Make sure to include the doctor's FULL name, not just Dr. Smith. There may be ten Dr. Smith's in town and I would need to know which one.

  • Current Medication List: This should include all prescription medications as well as allergies to medication. Also include all over-the-counter medications, vitamins and supplements. Please click here for a full review on medication lists needed and some common mistakes made.

  • Lab Results: Keep a copy of their labs every time they are taken. This information is incredibly helpful in an emergent situation. Remember that the medical field is not as technologically advanced as other fields at the current time. The lab in Kansas may not talk well with the lab in Florida if you are on vacation and the time delay to get this history could be critical.

  • Health Care Directives: These include papers such as CPR forms, Living Wills, Durable Power of Attorney for Health Care Directives and Power of Attorney for Financial. If you don't have these records or you aren't familiar with them, refer to the Legal section of this website.

  • Test Reports: Have on hand a copy of all test results, such as CAT Scan Reports, XRays, mammograms, ultrasounds etc. You will go through the same process of signing a release and they will send you a copy for your records.

  • Surgical and Hospital Records: Again, you will have to sign the release. The admission form and discharge note from the hospital is all you should need. Each are usually only one to two pages. For surgical reports, request the Operation Report. It is a summary completed by the surgeon of everything that went on during surgery including list of supplies and the make of any artificial components that may have been used.

  • Other: Anything else that you can think of that would help the medical field take the best care possible of your loved one. That may include religious preferences, including the name and number of a Rabbi or Priest for example, and even organ donation information and final wishes information.

    Remember, the goal is to help us help your loved one, not to invade privacy.

Obtaining your elderly loved one's personal medical records may be time consuming at first, but it is vitally important to assure that, in the case of an emergency, you are able to provide the medical providers with accurate and up to date information.

Have the files in a place you can easily get to them and just grab and go.

Once you have the system set up, keeping the copies of their personal medical records up to date is the next step.

Any time there is a medication change, or even a dosage change, make sure to update your files.

The pharmacy can also give you a print out of all medications a person in on, which may make the situation a little easier.

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