How to Obtain Your Medical Records
Samuels, Bruce, Wolfe, Sydney, Consumers' Research Magazine
Thanks to the Federal Freedom of Information Act, it is much easier for most of us to obtain copies of our CIA or FBI files than to get our medical records. Even though Americans will spend approximately $800 billion this year on health care, the records of why we went to the doctors or hospitals, what they found wrong (or right) with us, what diagnoses they made, what drugs they prescribed or surgery they performed, and whether we improved as a result, are generally kept from us.
Because of the continued demand for release of medical records to patients and the debunking of many of the myths about the "harm" to patients caused by access, the AMA now says that doctors should "on request of the patient...provide a copy or a summary of the record to the patient...."
Why Would You Want to See Your Medical Record? Seeing your record will make you a more involved and informed patient, more attentive to your health, and more in control of your own health care. It will provide you with continuity of care when you change doctors and help you protect your privacy by allowing you to inspect and correct information about you that will be released to others.
What Is Your Medical Record? A medical record may be brief or may run on for hundreds of pages. Depending on your reasons for requesting the record, you may want to see only part of it.
Medical records can be arranged in a variety of forms. They are given different names, like "H & P" for history and physical examination, "progres notes" to indicate part of a continuing record, or simply "patient record." Records can differ depending on whether they are for an office visit, a hospitalization, or a visit to a specialist.
Figuring out how the records are organized can be a challenge. Within the records created by the doctor, either hand-written or typed from dictation, a large amount of information should be detailed. How this is arranged is up to the doctor, but one common method is the "problem-oriented approach." The organization follows a format called S.O.A.P., which stands for "Subjective, Objective, Assessment, and Plan." The "S" part details the information from the patient or from outside sources. The "O" part records information gathered during the course of the visit and resulting investigation. The "A" is the doctor's summary impression of the problems of the patient. The "P" represents the doctor's plan for medical care and follow-up.
The "S," or subjective, part of the record for each visit usually identifies the patient and the reason why he is at the doctor's office that day. This part is called the History of Present Illness, or HPI. All of the details determined important to the record are included in this history section. For a patient who is seen without a particular complaint, a general survey of common health problems may be recorded.
Past Medical History, or PMH, is the section where previous serious medical problems are recorded, including hospitalizations, surgeries, allergies, and regular medications.
Social History, or SH, is where the details of your life pertinent to the record are found. It is reasonable for your record to include information regarding your living situation, marital status, diet, lifestyle, sexual practices, and habits-- including tobacco, alcohol, or drug use. One frequently ignored part of the social history is work. Your doctor should ask if your job is likely to contribute to health problems.
Family History, or FH, is where diseases or important details about relatives are noted, such as age and cause of death. Additionally, family history of certain cancers or familial diseases should be noted.
The ROS, or Review of Systems, is a place to fill in health details that might not be related to the problem of the day, but are important to record.
The "O," for objective, part of the record includes the information that is gathered by the doctor during the course of examination, and any additional laboratory tests, X-rays, or procedures that are performed. …