Medical Records Storage

This document is NOT intended to provide you with medical advice. You should consult the Doctor in your area for such information.

An issue that inevitably comes to all of us in the course of our treatment is where we saved this or that piece of information.  In this Patients’ Perspectives Document, we present a list of the information that you’re likely to need at some point.  we’ll also suggest several ways of storing this information.

Basic information about yourself that you’re likely to need sometime

  • Full legal name
  • Home address
  • Home phone number
  • Work phone number
  • Cell phone number
  • Employer name and address
  • Guardian name
  • Guardian phone number
  • Guardian cell phone
  • Guardian ‘s email address
  • Occupation and job title
  • Proof of citizenship
  • Photocopy of your driver’s license
  • Father’s name
  • Your marital status
  • Spouse  cell phone number
  • Number of kids
  • If unmarried, name, address, and phone number of emergency contact person
  • Your group number/name with insurance carrier
  • Contact information for your insurance carrier (name, address, and phone number of review office)


Prescription
:
In spite of the fact that the information necessary to take the prescription should be on the bottle when you receive it from the pharmacy, you should make a note in your personal notes about the prescription and your physician’s instructions for taking it.  That information in your notes should contain:

  • size of one dose, usually in milligrams (for most pills and capsules) and in milliliters (for most liquids)
  • how often to take the medicine, usually stated as number of times a day or every so many hours
  • time of day to take the medicine, usually stated as morning, evening, or with meals
  • potential side effects to watch for

This information is particularly important to note down when you are just beginning to use a particular medication.

At some time, you should transfer all the prescription information to a single sheet in your notes notebook so that all the prescription information is in the same place.  Particularly if you have several physicians providing your treatment, it’s important to have the same information readily accessible for all of them so there are no oversights.  It is also wise, from time to time, to have a single pharmacist review all of your prescription to be certain that there are not undesirable interactions among them.

Caution
If the prescription says to take the medicine with meals, be certain to find out whether that means one pill with some food at approximately the same time each day or literally one pill at each meal.  There is a huge difference between one pill and three pills!

Medical records
In this section, we’ll describe many the various kinds of medical records you’re likely to have.

Paper records
Each time you see a physician, each time you have a lab test, and each time you are hospitalized, some kind of paper report will be generated.  Having all of these available in one spot at certain critical times will be worth all the hassles you’ll probably get as you collect them.

The items which are necessary includes:

  • A photocopy of the note that’s added to your profile on each OPD visit.
  • Each set of lab results
  • Written report of each imaging procedure
  • Each written pathology report
  • Discharge summary of each hospitalization (Warning: This may not be completed when you actually check out of the hospital. So, you may need to collect it from the hospital’s Medical Records department the next time you’re in the neighborhood.)


Imaging records

Even though many medical centers usually to create digital records of your diagnostic images of all sorts, it is usually possible to get copies of the “film” records of each image, If you can get a digital copy of your images, you should do so because these are generally the “originals”. Additionally, you’ll probably receive them on a CD or DVD along with the software to run them, in case you’re interested. If your doctor wants an actual copy of the CD, giving him a copy of the original CD will give him a copy that is absolutely fine for use to read your images, whenever necessary.

Receipts
The last kind of information you’ll be collecting is payment receipts reflecting your co-payments, While it is not needed but you may need to come up with one or more of these receipts on short notice. Because of this, we strongly recommend that you keep them very well organized.

Finally
If you have other kinds of medical information or if you’ve found other ways of organizing the information, we encourage you to share your ideas with us for inclusion in this document.  Please use our feedback form to send us information.