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I have been a registered nurse, nurse practitioner and most importantly a patient advocate for over 20 years. I have worked in hospitals, homes and as a private consultant, always teaching patients how to speak up for themselves and to make well informed healthcare decisions that are right for them and help them to avoid all types of Medical Errors. The many things I have seen in healthcare led me write "What Did the Doctor Just Say." In it are all the steps every patient needs to take to remain safe in the healthcare system and avoid medical errors. My personal goal is help to save 100,000 people from the horrors of a medical error and I wrote What Did the Doctor Just Say? to help make that happen.

Monday, December 21, 2009

Do You Have a Personal Healthcare Record: Here's Why You Need One

Every healthcare provider you see creates a record of your care in a "chart." In that chart the provider documents your complaints, your test results and his or her treatment recommendations.  If you have seen more than one provider, you have more than one medical record.  All of those records contain different pieces of your medical history and none of your records or your providers has a complete picture of your care.
     When more than one provider orders treatments without anyone monitoring the "big picture," multiple problems can and do occur.  These problems include, but are not limited too: Duplication of imaging and laboratory studies; dangerous medication combinations; delays in care while waiting for records to be transferred from one office to the other, not to mention the time and money it takes to collect records.
      In addition to recording your current complaints and medical history, your medical record has clerical and administrative functions. The information contained in your medical record is translated into code numbers and given to your insurance company. The carrier then reviews your records to determine if the care you received was "customary and/or necessary."  Your carrier then goes on to make billing, payment and treatment decisions based upon what is written in your chart.
       Your medical record is also a central tool used in the investigating medical legal injury claims.  In a court of law your medial record will be used to reveal how your injuries occurred; who may be responsible for causing your injuries; and if you will be compensated for your injuries.  Clearly, your medical record is  a very important part of your healthcare safety

Benefits of Having a Personal Healthcare Record
Some of the benefits of maintaining a PHR are:
  • Constant and free access to your healthcare records
  • You will help prevent treatment delays that occur while waiting for records
  • You will be able to prevent duplication of services
  • You will be able to knowledgeably share information about your care
  • Will will be well organized, proactive, and accurate
  • You will foster feelings of respect from other members of YOUR Healthcare Team
  • You will get safe, more efficiently delivered care
Steps to Creating a PHR
  • Call of your providers, including any specialists you have seen, and request copies of your records
  • Obtain your pediatric records, they contain your immunizations and a record of any childhood diseases and treatments
  • Contact any hospitals where you were a patient and request complete copies of your records
  • Store your records in a three ring binder and organize it by dates or disorder. Each member of your family will need their own section in the notebook
Your PHR will contain many documents and could be a little overwhelming to compile.  I have found a wonderful template to help you get started, it is Having a PHR will help you to be safer in the healthcare system. In an upcoming post I will discuss how to check your records for errors, you won't want to miss that one.

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