Navigating the Health Care System

Keeping Track of Your Health Information

By Carolyn M. Clancy, M.D.

June 16, 2009

Say you're out of town, and you become ill. You go to the local hospital emergency room, where you are quizzed about your medications and allergies. Unfortunately—in the confusion and stress of the moment—you forget to mention that you're allergic to penicillin until it's too late.

It's not farfetched. Visiting a hospital or a doctor can be a stressful experience. Some situations—if you're weak from illness or a trauma, or are in place you don't know—may be confusing. You may not be able to remember every important detail.

But, good health care depends on good and thorough information. Your health information—the medicines you're taking, your allergies, your family history, what illnesses or surgeries you have had—is what makes you medically unique, and can affect your treatment. The one thing you forget to mention could be the detail that might save your life.

Many Americans receive care from doctors in many places. We are a mobile society; we change towns, we change doctors, we change jobs and we change health insurers. But, your doctor's medical charts and other health information don't automatically appear at different doctors' offices or hospitals. Don't assume your doctor has all the relevant information at his or her fingertips. Usually, in fact, the doctor does not.

Because of this, it's up to you to keep track of your own health information.

Some people do so by creating and maintaining a personal health record (PDF file, 225 KB; Plugin Software Help), or PHR. PHRs typically are health records that can be offered by your doctor or insurer but are maintained by you, the individual (rather than by a provider or insurer). Usually, you control who can see or use the information in a PHR.

An ideal PHR provides a complete summary of your health history by compiling information from many doctors and other care providers. In some cases it makes information available via the Internet to anyone you allow to see it. Other types of PHRs can be saved on your computer.

If you're comfortable storing and updating your information in this fashion, a PHR may be for you. If not, you should keep track of your paper records by storing them all in one place. You should organize these records in a way that you find useful, and make sure that a friend or family member knows where to find them. Keep in mind that Federal privacy rules (PDF file, 337 KB; Plugin Software Help) give you rights over your health information, but allow this information to be passed along at certain times.

Some Medicare and prescription drug plans offer PHRs. If you belong to one of these plans, check your plan's Web site or contact the member service department to see if one is available.

There are two important reasons to keep good records about what has happened with your health care. The first is that your record could be the only information source at critical moments, such as an emergency. (Even if you're only able to offer basic information to new doctor at that time, that information can be very helpful.) The second is that keeping your own record helps you take better care of yourself and helps you ask better questions about your care.

What kind of information should you keep track of? Anything that may affect how a doctor might treat you. At a bare minimum, you should list, in detail, information on the following:

• Any illnesses or conditions in your own history, such as whether you have heart disease.
• Any potentially relevant family history of illness (such as diabetes, cancer, or high blood pressure).
• Prescription medicines you're currently taking, including dosage information.
• Known reactions to medications or allergies.
• Test results and immunization records.

You also should include information on over-the-counter medicines and vitamins you regularly take and preferences such as a living will on your record. And, the names and phone numbers of your doctor(s) and insurance company also are important.

You can add more information to your record as you see fit. Some PHRs give good guidance on what to add, and a number of organizations offer guidance on how to select and use a PHR. Your PHR doesn't have to be fancy, but it should be organized. What's important is that the information you put in your record be as complete, accurate, and accessible as possible.

I'm Dr. Carolyn Clancy, and that's my advice on how to navigate the health care system.

More Information

MedlinePlus
Personal Medical Records
http://www.nlm.nih.gov/medlineplus/personalmedicalrecords.html

Centers for Medicare & Medicaid Services
Learn More About Personal Health Records
http://www.medicare.gov/phr/LearnMoreAboutPHR.asp

Department of Health and Human Services
Privacy and Your Health Information
http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/consumer_summary.pdf [Plugin Software Help]

Current as of June 2009

Internet Citation:

Keeping Track of Your Health Information. Navigating the Health Care System: Advice Columns from Dr. Carolyn Clancy, June 16, 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/consumer/cc/cc061609.htm