What Are Medical Records?
Each time you climb up on a doctor's exam table or roll up your sleeve for a blood draw, somebody makes a note of it in your medical records. Back in the day, your doctor scribbled notes on a paper chart. That still happens sometimes, but many health care providers now keep electronic records. You might hear medical people call these EHRs — short for electronic health records.
Electronic records make it easier for all your doctors to see the same information. So if your dermatologist wants to give you a prescription, he or she can check to see if other doctors have given you medicines that might react badly with the new one. Having a central record like this can help doctors give the best care — and take some of the burden of remembering off the patient.
It's still good to know about your medical records, though. At some point, you'll need to get information from them, like if a college or new job needs to see a record of your immunizations before you can start. Or you might have chosen a new doctor and want him or her to know your full medical history.
As you start taking charge of your own medical care, it helps to know what's in your medical records, how you can get them when you need to, who else is allowed to see them, and what laws are in place to keep them private.
What's in My Medical Records?
You might picture your medical records as one big file in a central storage facility somewhere. But actually your records are in lots of different places. Each specialist who treats you keeps his or her own file, and they're all part of your medical records.
Even electronic records aren't simple. There are different programs and software, and not all medical offices use the same system. For that reason, some states now manage records in a way that lets all your information be shared between different health care providers.
Your medical records contain the basics, like your name and your date of birth. They also include the information you give to your family physician, dentist, or other specialist during an examination. So your answers to all those questions doctors ask — like how you're feeling that day — go into your records. Your records also have the results of medical tests, treatments, medicines, and any notes doctors make about you and your health.
Medical records aren't just about your physical health. They also include mental health care. So if you went to family therapy back when you were 6 and your parents were divorcing, it will be somewhere in your records.
Can I See My Records?
Yes. U.S. law gives patients the right to see, get copies of, and sometimes even change their medical records.
If you're younger than 18, your parent or guardian will probably need to ask for copies of medical records on your behalf. But as more states allow people under age 18 to take charge of their own health services, you may be able to get your own records.
There's a law in the United States that limits who can see medical records. The law, known as HIPAA, is meant to help patients by protecting their medical information from prying eyes. You're covered by HIPAA after you turn 18. At that point, you need to give written permission for people to see your medical records — even your parents.
Medical records can be confusing for people who aren't trained to read them. That's especially true for test results or images like X-rays and MRIs. Something that can look scary might be nothing to worry about. So if you do look at your records on your own, keep that in mind. Ask a doctor if you have questions.
How Do I Get Them?
To get your records, start by figuring out who has the information you want. If it's dental information, get in touch with your dentist's office. If it's a general health issue, you'll probably want to talk to your family doctor.
When it comes to asking for medical records, different health care providers have different ways of doing things. Some might ask you to fill out an authorization form. If so, you'll want to be ready with information like this:
- Dates you had a treatment or service (like a hospital stay). If it's been a while and you don't remember exact dates, ask for records from a range of dates, such as 2000-2005.
- Which information you want. Do you need the entire record or just part of it? Specific test results? X-ray films, blood work results, etc.?
- How you want to get the information. Do you just want to look at your records to find out what's in them? Do you need your own copy? Do you want to have a copy sent to another health care provider? Both?
A health care provider's office might charge a fee to cover the cost of having someone make copies. Some offices put test results and imaging studies on a CD-ROM. You'll probably have to pay mailing costs to have the records sent to you or another doctor (if you won't be picking them up in person).
How Long Does it Take?
The law gives health care providers up to 30 days to provide copies of medical records, but almost all health care organizations supply records a lot faster than that. Most people get their non-critical care records within 5 to 10 business days. If records are needed faster — like when a patient needs medical treatment — the health care provider holding the records usually releases them immediately.
If you need to get records for non-emergency situations (like switching to a new doctor), it's best to give lots of notice. Let the medical provider who has your records know that you'd like copies a few weeks ahead of any appointments with your new health care provider.
Can They Say No?
Health care providers can say no to requests for records — but it almost never happens. When it does, it's because a doctor's office is trying to protect a patient's privacy or safety. For example, they may say no to sharing information if they're not sure the person asking for the records has a right to see them. Or they may not release records if they think it will lead to a patient being harmed.
If health care providers deny access to records, they must give the reasons why in writing within 30 days. If any request for medical information is denied, a patient has the right to ask for the decision to be reviewed again.
What if I See a Mistake in My Medical Records?
If you notice something missing or something you think is wrong in your medical records, you have the right to ask for a correction. Your doctor's office will explain how they handle changes to your records and what you need to do to request a change. The law gives health care providers 60 days to make a change or deny the request.
Who Else Can See My Records?
Your information can be used and shared with the following people or groups, when needed:
- other health care providers when needed to support your treatment and care
- insurance companies, Medicaid, and other groups responsible for paying doctors and hospitals for your health care
- public health agencies when needed to protect the public's health (for example, reporting when diseases like measles or the flu are in your area)
- law enforcement agencies (for example, reporting a gunshot wound to the police)
- parents or guardians if you are younger than 18
- family, relatives, friends, etc. — but only if you (or a parent or guardian, while you're under 18) give permission
What About My Parents?
Parents have access to their kid's medical records until the child is 18. However, many states now leave it up to doctors to decide if they tell parents some information — like about sex or drug use, for example. The law also states that parents can no longer see a teen's medical records if they've agreed the child can see a doctor confidentially.
Most hospitals or doctors make every effort to protect patients' privacy when it comes to the sensitive information in their medical records. Sometimes a health care provider will feel that it's not in a teen's best interest to give information to parents, even when a child is younger than 18.
For mental health records (like the notes a therapist takes during counseling sessions) the age when parents no longer have access to a child's medical records is 15 or 16, depending on the state.
After you reach 18, your parents cannot see your records — by law. For some people, that may not be a problem. It may even seem like a good thing! But what if you have a health problem and need your parents to make decisions about your care if something happens? If you want your parents to have access to your records after 18, you'll need to sign a document authorizing them to do so, just as you would with anyone else.
Should I Keep My Own Medical Records?
It's a great idea. Many health care experts recommend that patients keep their own personal medical records (PMRs). If you do this, you can bring your PMRs along on visits to specialists, new doctors, or even an unexpected trip to the emergency room. Because PMRs are so useful, you can download apps that help you keep records of your most important information.
Your PMR should include the following information:
- your name, date of birth, blood type, and emergency contact
- date of last physical exam
- dates and results of past tests and screenings
- major illnesses and surgeries, with dates
- any injuries you've had and/or illness for which you've been treated
- any allergies to foods, medications, household items, etc.
- a list of all your medicines, dosages, and how long you've been taking them
- chronic diseases, if any
- a history of illnesses in your family
- any accommodations you may need to make medical decisions (such as sign language interpreter, information written in large print, picture symbols, etc.)
Once you compile your PMR, you can keep it up to date by requesting test results and other medical records as they come up in the future. An app is a great way to get access to your medical information all the time. But as old fashioned as it sounds, it's still best to keep a paper copy of the most important information in your wallet, just in case there's an emergency.
Reviewed by: Cory Ellen Nourie, MSS, MLSP
Date reviewed: February 2015