Your Medical Record And Your Rights
Whenever a person is a patient in any hospital in the U.
S.
, we leave behind a medical record.
This record is meant to be a detailed list including what we were originally admitted for and how that diagnosis was treated (i.
e.
all medications, surgeries, therapies, etc).
But, once we are gone from the hospital, what happens to that medical record? And, even more important, who owns that information and controls how it is shared? Much of the information is encoded.
Some of it is shared (at his or her request) with your doctor.
A great deal of it is shared with your insurance provider.
For many years, this information was treated by the hospital as a deep, dark secret that only they (and your insurance company, of course) were privy to.
It practically took an act of Congress for a patient to see the information contained within their own medical record.
That has, thankfully, changed.
Any patient, nowadays, can request a copy of their medical record and it is actually a good idea to do so.
You will want to make sure that the information contained within the record is both accurate and fair.
In the past, doctors sometimes added cryptic little remarks (as "patient notes") that could actually have a damaging effect on your health care coverage.
Be aware that much of what you read will be in "medical-speak" and you may have to ask your doctor what it means.
If you are changing physicians or want to get a second opinion (which is always your right), you will need a copy of your medical record.
You must call the Medical Records department at the hospital and tell them you will be requesting a copy.
You will need to pick it up on a week day (Medical Records are usually closed on the weekend) and you will need your identification to do so.
Some hospitals require you to come in person to submit your request, which means you will have to make two trips.
In the past, your medical record was all on paper; nowadays, you will probably be handed a CD but if there were any x-rays performed, you will also get a packet with the x-rays inside.
Some hospitals require you to return the x-rays within a certain period of time as they are, technically, the property of the hospital.
Should you ever be re-admitted to that hospital for any reason, the hospital will already have you in their data base and all the information from your previous visit will also be there, for reference.
This is actually a good thing, as most of us have faulty memories, at best, when it comes to dates and exact treatments, especially if they took place years in the past.
If you are admitted to a different hospital, they will be able to request and access those records, as well.
S.
, we leave behind a medical record.
This record is meant to be a detailed list including what we were originally admitted for and how that diagnosis was treated (i.
e.
all medications, surgeries, therapies, etc).
But, once we are gone from the hospital, what happens to that medical record? And, even more important, who owns that information and controls how it is shared? Much of the information is encoded.
Some of it is shared (at his or her request) with your doctor.
A great deal of it is shared with your insurance provider.
For many years, this information was treated by the hospital as a deep, dark secret that only they (and your insurance company, of course) were privy to.
It practically took an act of Congress for a patient to see the information contained within their own medical record.
That has, thankfully, changed.
Any patient, nowadays, can request a copy of their medical record and it is actually a good idea to do so.
You will want to make sure that the information contained within the record is both accurate and fair.
In the past, doctors sometimes added cryptic little remarks (as "patient notes") that could actually have a damaging effect on your health care coverage.
Be aware that much of what you read will be in "medical-speak" and you may have to ask your doctor what it means.
If you are changing physicians or want to get a second opinion (which is always your right), you will need a copy of your medical record.
You must call the Medical Records department at the hospital and tell them you will be requesting a copy.
You will need to pick it up on a week day (Medical Records are usually closed on the weekend) and you will need your identification to do so.
Some hospitals require you to come in person to submit your request, which means you will have to make two trips.
In the past, your medical record was all on paper; nowadays, you will probably be handed a CD but if there were any x-rays performed, you will also get a packet with the x-rays inside.
Some hospitals require you to return the x-rays within a certain period of time as they are, technically, the property of the hospital.
Should you ever be re-admitted to that hospital for any reason, the hospital will already have you in their data base and all the information from your previous visit will also be there, for reference.
This is actually a good thing, as most of us have faulty memories, at best, when it comes to dates and exact treatments, especially if they took place years in the past.
If you are admitted to a different hospital, they will be able to request and access those records, as well.