Keep track of medical records

PostedJanuary 5, 2023

UpdatedJanuary 10, 2023

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Summary

Well-organized medical records help caregivers, doctors, and other health care providers give the best care to people. This article explains why keeping track of medical records is important and offers steps to take to carry this out.

Why keep track of medical records?

Well-organized medical records help caregivers, doctors, and other health care providers give the best care to people. They allow caregivers to understand the person’s recent health history and pass this information along to doctors, nurses, and lab technicians. They give medical professionals key information, such as test results and previous procedures, which enable them to provide better care.¹ In addition, a well-kept set of records lets ER doctors, new primary care providers, and specialists get up to speed quickly and make informed decisions.

The main steps in keeping track of medical records are to make a list of health care providers, get HIPAA clearance, gather paper copies of health care records, request missing records, and create a system for sharing the records.

Make a list of doctors and other health care providers

Making a list of all medical and health care professionals who are involved with the person’s care is a good first step. Not only does it put important information in one place, but it also can be used as a checklist for which medical records have been obtained.

For each provider, the list should include:

Name and contact information
Their role in the person’s care
Dates of appointments for the past year
What was done during the appointment

Get HIPAA clearance

To keep track of medical records, the caregiver must be able to access and make copies of them. Under the HIPAA Privacy Rule, the person receiving care needs to give written permission for anyone but themselves to receive their health care information or request their medical records. (The exception is the person’s legal representative, such as their medical power of attorney/health care proxy, or legal guardian.)

The person receiving care can give this written permission by filling out a HIPAA Authorization form, also known as a Medical Release form. If they are hesitant or confused about this process, it can help to print out the release form, which is simple, short, and clear. When choosing which scope of permission to check off on the form, ideally the person will let the primary caregiver and other family members have access to all relevant medical information.

Gather health care records

With the permission and help of the person receiving care, find and gather any copies they already have of all their relevant medical and health care records for at least the past year. Electronic records, such as those in the electronic patient portal of a hospital or care provider, may be printed out if desired. If the portal has a “Blue Button” that means the site has a download function, and a printable copy of the person’s information can easily be obtained this way.² However, electronic records may also be stored in a secured shared drive (such as Google Drive, One Drive, or Dropbox, for example), which all authorized caregivers have access to. Records should include:

Doctors’ clinical notes
Records from the ER, surgeries, and treatment facilities (chemotherapy, radiation, dialysis, etc.)
Lab results (for instance, blood count, thyroid function, kidney function, urine analysis)
Imaging and other diagnostic results (for example, biopsies, x-rays, MRIs, CT scans) for the past year
A complete medication list, including any stopped within the past six months
A list of chronic health conditions
Pharmacy receipts and printouts for prescription drugs
Health insurance policies
Living will document
Power of attorney documents
Portable medical orders (known as POLST, MOLST, MOST, and IPOST, depending on the state)

Request missing medical records

If records are missing, you can usually get a medical-records request form from the doctor’s office or medical facility and send it back by email, fax, or the postal service. If a form is not available, you or the person receiving care can write a letter making the request.

Medical records for the past six years should be available from doctors, hospitals, specialists, and labs. This is the case even if the doctor, technician, or other provider who interacted with the loved one has retired or left the practice.³

Make sure that you are getting “doctor-level” information, such as lab results and clinical notes,⁴ not just summaries of patient visits. Ask for the emergency room clinical notes, hospital admission history and physical, and hospital discharge summary.⁵

Set up a system for sharing records

The simplest system for sharing print records with medical professionals is to put copies in a binder. You can show health care providers the binder when they visit the home, and take it with you to the person’s appointments. It’s a good idea to keep a few different print copies of the most important records in different places such as a car, purse, or with other relatives or caregivers.⁶ If using a print binder, it’s also a good idea to create a backup by scanning in the documents as PDFs and saving them in a shared drive (such as Google Drive, One Drive, or Dropbox, for example), flash drive, or computer.

If the person receiving care has a large number of providers or procedures, or a long and complex health history, it may be worthwhile to enter the information into an online personal health record (PHR). While there are various free PHR apps available, be aware that many apps only work on certain devices (for example, Apple or Android); that many will only work on the most recent versions of a device; and that if an app is discontinued, the security function may no longer work and the records may not be able to be transferred.⁷ A full Profile for the person receiving care in the Maia app can serve as a useful starting point for a health-records summary.

Related information

10 things I wish I had known about caregiving

Avoid delayed decisions and discord

Balance care responsibilities

Create a care plan

HIPAA authorization for medical records

Portable medical orders

External supporting content

Medical Records: Getting Organized

Tips for Organizing a Medical History

HIPAA Release Form

6 Reasons Why Getting a Copy of Medical Records Improves Senior Health