The process of requesting your medical records can be a daunting task, especially if you are not aware of why the records are required, or if you don’t know the rules, the laws and the basic requirements that could possibly ease the process out.
A medical report is something which everyone has, at least one, in their lifetime. A medical record can be defined as a record of a patient’s health and medical history. Depending on the level or need of care a patient has, records may vary, but all medical records will contain some common information. These records are crucial and hence,
requesting medical records for your keep and access is a must for all.
Some common types of information that a medical record holds:
a) Personal identification information
Each medical record must have some specific personal identification information, such as social security, or an identification number issued by government body which identifies the correct patient.
b) Medical history
Patient medical history includes all diagnoses, medical care, and treatments, allergies, and even the lack of need for medical care.
c) Family medical history
One of the most important parts of your medical records is the information about the family’s health. That’s mainly to keep a record of genetic health concerns.
d) Medication history
Providing complete information about every medicine taken in, under prescription or not, is important to keep the medical records in proper way. A medical professional needs to know about herbal, over the counter, home remedies, prescription medicines and even illegal drug use because of the way these can affect our health not only immediately, but over time.
e) Treatment history
Being aware of what treatments have been given and whether they worked or failed is of significant information to save time and money while providing the right treatment.
f) Medical directives
Medical directives hold the documents in a file that tells the treatment team the wishes of the patient in the event that they are unable to speak for themselves regarding their medical care.
g) Test results
The tests done, their bills and the detailed report summary, if you were hospitalized ever, are kept with utmost care.
Objectives of maintaining medical records:
Medical records are maintained mainly because of the following reasons:
• Monitoring of the actual patient
• Medical research
• Medical/dental or paramedical education
• For insurance cases, personal injury suits, workmen’s compensation case, criminal cases, and will cases
• For malpractice suits
• For medical audit and statistical studies
Things to keep in mind while requesting medical records:
• Your name, including your maiden name (if applicable)
• Social Security number
• Date of birth
• Address and phone number
• Record(s) being requested
• Date and duration of treatment (months and years) under the doctor’s care
Care taken while issuing medical reports
a) Prescription
The prescription should be preferably on the OPD slip of the institution or the letter pad of the doctor. rescription must contain—patient’s name, age, sex, address and institution/hospital name. Prescribed drug should be preferably in capital letter or else clearly visible.
b) Lab investigation reports
All lab investigation reports including X-ray reports, ultrasound reports, computed tomography, magnetic imaging resonance and histo-pathological reports should be issued by a qualified person.
c) Referral notes
Referral notes should mention the date and time along with treatment given. Also, the carbon copy of the same should be kept especially in the case of critically ill patients.
d) Discharge card
Condition of the patient on the admission, investigation done, the treatment given and detail advice on discharge should be written on discharge card by the consultant in-charge.
These are the information and things to keep in mind while issuing and
requesting medical records.
