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Protecting Your Health
You and Your Medical Record
How can you access it, and what’s in it for you?
Did you ever wonder what’s in the medical record your doctor updates on each visit? You should. It’s all about your health, and some of the information can help you better manage your own care. Here’s what you need to know:
What’s in your record? Besides basic identification, insurance and contact information, it includes:
- your health history and reports on each exam.
- test results, prescribed medications and referrals to specialists.
- your plan of care, with instructions for self-care and return visits. If you have diabetes, for example, this might include a schedule for insulin injections and blood glucose testing, as well as dietary guidelines.
Why is it important? “The medical record helps your doctor put current health issues in perspective, track your progress, and oversee your care for a chronic disease or ongoing health issue,” says family physician Jack Lenhart, M.D., of Lehigh Valley Hospital and Health Network. “But you need to be aware of this, too, so you can be a partner in your care.”
Talk with your doctor to make sure you have all the information you need, including important test results and any health issues you should watch, Lenhart says. Make sure all specialist reports and test results are sent to your primary doctor so they’re in a central place.
Can you see your record? You’re legally entitled to a copy of your medical record (for a fee) simply by asking the medical receptionist at your doctor’s office, says Fran Miranda, patient safety officer at Lehigh Valley Hospital and Health Network. “You’re only excluded from information about your mental health that is deemed harmful for you to read,” she says.
What about your privacy? Your health information is protected by the Health Insurance Portability and Accountability Act (HIPAA). Only the local health bureau, other health care providers, insurance companies and some government agencies can view information to ensure you receive the care you need when you need it.
What is an electronic medical record? Some physician offices store the information on their patients’ records electronically. It allows doctors and hospitals to view the record quickly, clearly and remotely. You, too, may view your electronic medical record during an office visit, says Donald Levick, M.D., physician liaison to information services at Lehigh Valley Hospital and Health Network. “Some practices use a secure, Web-based access called RelayHealth. Through this, you and your doctor can view portions of your record on a secure web site, and you can use it for asking nonurgent advice or refilling prescriptions.”
Want to Know More? For a guide to the most common medical conditions, specialists, tests and medications, call 610-402-CARE or click here. This page last updated 2/12/08 04:08 PM
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March April 2005
Eating Healthy
Staying Fit
Caring for Mind and Body
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Heart of Healthy You
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Coping with Illness
Aging Well
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