Many experts recommend that we keep personal medical records. There are good reasons for doing so. They may be especially important for us as retirees who, as we age, are increasingly likely to draw on health services.
- Do you like to travel, perhaps to foreign countries? Do you like to get out and about in public places about town? Well then, do you carry on your person important medical information useful to first responders in case you have an accident or a medical emergency?
- Perhaps you have had to attend at an emergency department and have discovered that you had to repeat at least parts of your medical condition and history over and over -- to the triage nurse, a clinical clerk, an intern, a resident, an attending physician, a technician, a specialist. It is best to be prepared in advance with your medical information: you may get faster, better service.
- "It is extremely likely that the full picture of your health history, including records of tests and treatments, is not available in one place. Until this scattered method is improved, the onus is on you to assemble and manage your own record... Remember the evacuees from New Orleans who lost all records in the food." (M. Decter & F. Grosso, Navigating Canada's Health Care: A User Guide to Getting the Care You Need, Toronto: The Penguin Group, 2006, p. 88
- "...the Canadian hospital system, in dealing with 2.5 million admissions produces 185,000 adverse events, of which 75,000 are preventable. These adverse events lead to between 9,250 and 23,750 preventable patient deaths...Only you armed with knowledge and information can take steps to at least minimize some of the most serious threats to your safety." (Decter & Grosso, p. 296, bold emphasis added.)
The following information and suggestions are intended to assist RALUT members in putting together their own health records. Once you understand the various types of medical records, you can decide what types you wish to gather, records that will fit your circumsances and needs.
To avoid feeling overwhelmed, it might be best to start by keeping it simple: start perhaps with your Emergency Medical Record.
It seems reasonable to divide one's medical records into four types, which we will expand on later.
Type I Emergency Medical Record
A brief synopsis of medical information carried on your person that is useful in case of an emergency while travelling or out in public.
Type II Personal Medical History
A brief summary, at least, of the important elemens of your own medical history, something like what the College of Physicians and Surgeons of Ontario (CPSO) Policy on Medical Records (see below) calls "The Cumulative Patient Profile (CPP)".
Type III Family Medical History
A brief summary of significant health problems that have afflicted blood relatives and, where applicable, their cause of death.
Type IV Fact Sheets for Medical Visits
A summary of the facts especially relevant for a specific visit to a doctor, including the "CC" (Chief Complaint) and "HOPI" (History of Present Illness) that practitioners usually want to know before making a further examination or ordering tests.
RALUT members may have detailed questions about why is it simportant and useful to keep medical records, what should go into them, and how they can get the necessary information. Here are some FAQs:
Frequently Asked Questions
FAQ1: Again, why is it important for me to have my own medical records?
Answer:
- A Type I record is important to carry on you to give first responders essential information in case tyou have an accident or a medical emergency, such as a heart attack, while travelling or in a public space.
- A Type II record gives you easy access to your important health information while travelling or when your physician is not available.
- Type II and III records can aid a physician in making a diagnosis of your ailments, if s/he does not already have them.They can also be useful information to give yourother caregivers. And especially in case of ailments with a genetic component, they can be for the benefit of your descendents by helping them record their own family medical history.
- Your medical records in your own psosession can be helpful and save time if you have to attend an emergency department, walk-in clinic or another medical practitioner.
- Making a Type IV record can assist you in giving a clear, detailed and accurate account of a medical problem for which you seek advice and treatment.
- In general, having your own medical records can help you knowledgeably discuss your health with healthcare providers and thus receive better service from the healthcare system.
FAQ2: Where are my medical records?
Answer:
- Your own memory, together with any documents at hand, is a good starting point. So to begin, you could just compile your medical records from these, because it is likely that you will recall important events, such as surgeries, diseases, disorders and the like. You can then access more formal records to verify your memories and to add pertinent details.
- Your primary care provider's (e.g., family physician's) records would normally be a primary source of accurate information.
- Your pharmacist may well have a good electronic record of your medication history. (Beneficiaries of the Ontario Drug Benefits Plan who are currently taking a minimum of three chronic prescription medications are entitled to an annual 30 minute private consultation with a pharmacist. See http://www.medscheck.ca .
- But your records are likely to be scattered in many other places: your former practitioners, specialists, consultants, alternative practitioners, hospitals, clinics, medical labs, dentists, optometrists and the like. You may have to hunt them down, if you want your records to be accurate and complete.
FAQ3: Who owns my medical records?
Answer:
- By law, in Ontario, physicians own your medical records in their physical form , because they are required to keep them for audits by the College of Physicians and Surgeons and for other legal purposes. See http://www.cpso.on.ca .
- However, you as the patient own the content of the records and have the right to access them and have them copied.
FAQ4: Can I keep my medical records private?
Answer:
- In general, the answer is, yes. The information belongs to you, and you permission (explicit or implied) is normally required for it to be shared. So generally speaking, you can decide for yourself what personal medical records you want to collect and keep yourself, how you want to safeguard them, and with whom you want to share them.
- However, your records held by practitioners are subject to the provisions of PHIPA (Personal Health Information Policy Act, Ontario, 2004), which sets out your health privacy rights and certain limitations on them. See Your Health Information: Your Rights .
FAQ5: What will it cost me to get my medical records from a practitioner?
Answer:
The Ontario Medical Association publishes recommended tariffs on a wegbsite not accessible to non-members of the Association. This type of cost is not usually covered by OGIP or GreenShield. According to one family practitioner, the tariff for faxing and photocopying records for the patient's personal use is $25; the transfer of medical records at the request of the patient is $35 for up to five pages and $1.50 for each subsequent page. You may wish to discuss and negotiate these fees with you practitioner.
FAQ6: Won't we soon all have our medical records in electronic form, perhaps on a small chip or card that we can carry on our persons, thus obviating the need for gathering our own medical records?
Answer:
Yes, it is likely that in the future this will be the case, but progress in this direction will likely be slow and spotty. In the meantime, it would be wise to collect your own records.
FAQ7: Gathering my own records seems like an arduous task. How can I get started?
Answer:
You might start with your Type I record, and then move on to the other types.Do not let the best and complete be the enemy of the good and partial. Some useful records that suit your convenience are better than none at all.
We turn now to what might be included in the four types of records.
Type I Emergency Medical Record
You can and should tailor this to your personal circumstances. Think:
What would a first responder, such as a paramedic or emergency department, need to know immediately about my general condition in order to treat me appropriately and to notify appropriate persons?
This might change from time to time, For instance, you may be travelling and need certain vaccinations.
Paramedics are trained to look for identification, such as a friver's licence, so it is a good idea to record the information on a wallet-sized card with your licence or the like. The Heart and Stroke Foundation of Canada gives donors a small, red plastic folder for this purpose.
Here is a check list to get you started, and then you can decide what you want to include:
- Personal identification: full name, address, phone number
- Emergency contact person and person with power of attorney for personal care
- Insurance information: record contact information for your insurers, such as OHIP and Green Shield. To use your insurance, you will also need your OHIP and Green Shield cards
- Name, address and phone number of primary care provided, such as the family doctor
- Allergies, such as to codeine, sulpha drugs, morphine, penecillin, ASA (aspirin), X-ray contrast dye, insect bites, food products
- Vaccinations, such as against smallpox, tetanus, flu and exotic diseases
- Meedications, including herbal medications and non-prescriptiom drugs (such as, for example, 81 mg prophylactic aspirin, which affects clotting time) currently being taken, including dosage and timings
- Chronic conditions such as asthma, chronic bronchitis, emphysema, diabetes mellitus, hypertension, arthritis, glaucoma, epilepsy, Parkinson's disease, kidney disease, a heart condition including, for example, an abnormal EKG.
- Information regarding your vision, hearing, mobility and the like, such as the use of a hearing aid, contact lens or spectacles (record the prescription for your visual aids), removable dentures, canes, crutches and other aids
- Other important medical consitions, such as the emplacement of a pacemaker or stent.
Type II Personal Medical History
CPSO recommends to practitioners, but it does not strictly require, that each patient's chart contain a Cumulative Patient Profile (CPP), a brief summary or "snapshot" of essential information about the patient that gives a picture of the patient's overall health. Here is a list of the informatuion that they recommend that it contain, quoted from "CPSO Policy Statement -- Medical Records" (page 7), as well as Appendix D sample forms:
- Patient identification (name, address, phone number, OHIP number)
- Personal and family data (occupation, life events, habits, family medical history)
- Past medical history (past serious illnesses, operations, accidents, genetic history)
- Risk factors
- Allergies and drug reactions
- Ongoing health conditions (problems, diagnoses, date of onset)
- Health maintenance (annual exams, immunizations, disease surveillance, such as mammograms, colonoscopy, bone density
- Consultant's names
- Longterm treatment (current medications, dosage, frequency
- Major investigations
- Date the CPP was last updates
- Contact person in case of emergency
- [Note absence of explicit obstetric/gynaecological history!]
If your physician has a CPP for you, the simplest thing to do is to ask for a copy. if not, the list gives you some ideas for completing some form of it for yourself.
Type III Family Medical History
Your family medical history can be an important piece of evidence in diagnosing an ailment affecting you or another blood relative. You might start with your close blood relatives:
- Parents
- Paternal grandparents
- maternal grandparents
- Siblings
- Other blood relatives with a health problem that might be of genetic significance
Some of the important diseases to record are:
- Diabetes
- Cancer
- Heart disease
- Kidney disease
- Arthritis
- Neuromuscular disease
- Mental disorders
- Cause of death, where applicable
Sometimes this information is difficult to get because no records were kept or they were lost. Sometimes relatives are reluctant to disclose medical information about themselves, in which case, a certain delicacy is required. See"How to compile your family medical history" at http://www.mayoclinic.com/health/medical-history/HQ01707
Type Type IV Fact Sheets for Medical Visits
It helps to be well-organized when attending a physician's office, clinic or hospital for a medical condition. When we are in pain or discomfort or are apprehensive, we tend to forget salient facts, so it is best to write them down in advance. Similarly, it is a good idea to make notes (or have someone with you do it for you) of what the health provider said to you about your diagnosis and treatment.
Of course, such fact sheets are highly specific to the occasion, but a few general points can be made about standard procedures.
- The physician will want to know the "CC" (the Chief Complaint), the major health problem or concern that you are presenting. Try to be as specific as possible. For example, if you have an abdominal pain, try to describe its location and character -- stabbing, dull, etc.
- The physicial will want to know the "HOPI" (History of Present Illness), the time of onset of the symptoms you are having, their frequency, their duration, accompanying facts, and so on.
- The physician may want to know, if s/he does not alreadyknow it, the "HPI" (History of Past Illness) -- which is where the personal medical history you have compiled is valuable
- A good checklist of questions you may wish to ask about diagnosis, medications, tests, treatments, surgery, options, hospitals, services and health plans is available at http://ahrq.gov/questionsaretheanswer/QuestionBuilder.aspx .