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School of Medicine
Medical Records: Getting Organized
Struggling with your own files or those of a loved one you care for? These steps and tools—from a Johns Hopkins expert—can help you clear the clutter and make accessing what you need quicker and easier.
In a study of senior cardiac patients, researchers found that those who kept a personal health record enjoyed better health—perhaps because they and their caregivers could better see their health picture. In an emergency, having records at the ready can also be helpful for health care providers.
But getting health information organized can seem so overwhelming. The good news: You can get the upper hand on records and make organizing key health information for you and your loved ones easier with these tips from Johns Hopkins geriatric medicine physician Alicia Arbaje, M.D., M.P.H.
Create a doctor directory.
Jot down all health care providers, their contact info and the role they play in care. This record is especially important if you are a caregiver juggling many contacts and appointments for a loved one.
Keep these records at the ready.
Key records more than a year old may be packed away. But keep documents from the past year readily accessible, including:
- A family health history (particularly parents, siblings and grandparents)
- A personal health history (conditions, how they’re being treated and how well they’re controlled, as well as important past information such as surgeries, accidents and hospitalizations)
- Doctor visit summaries and notes
- Hospital discharge summaries
- Pharmacy printouts that accompanied prescribed medications. In a study of patients taking blood pressure drugs, about 40 percent were unable to name a single one of their medications.
- Test results (such as blood work, urine tests, X-rays, MRIs, bone density scans, mammograms and prostate screenings). If you or your loved ones have certain lab tests done regularly, a record will enable you to track changes from year to year and ask informed questions.
- Insurance forms related to medical treatment
- Legal documents such as a living will and medical power of attorney
Log symptoms and side effects.
If you or a loved one has a chronic condition, keep a log of relevant factors like blood pressure and blood sugar. If you can, include the time of day so that your doctor can help figure out whether changes in your health measurements are related to the condition or to medications. Note any changes in nutrition, activity and stress levels.
Also keep a log of how you or your loved one responded to any medications and treatments. Be specific with the name of the medication, the dose and what happened. This record will come in handy when trying to determine adverse effects of treatments down the line.
Take advantage of technology.
Health care providers, hospitals and insurance plans may offer online records that you can access. Apps and programs can help you manage health records—ask your primary care doctor for recommendations.
If you use any online tools, be sure to record (and share with a backup contact) the log-ins and passwords.
Whether you use high-tech record keeping or a good old-fashioned box or file folder, be sure to keep several copies of your medical records. If you can keep one in your car or purse it will ensure you always have it when you go to the doctor or if you unexpectedly end up in the hospital. It’s also smart to stash a copy of health records in a safe and/or with someone else in case of natural disaster.
#TomorrowsDiscoveries: Talking About Family Health History— Dr. Joann Bodurtha
#TomorrowsDiscoveries: A knowledge of family history can help improve health. Dr. Joann Bodurtha studies genetic health information and how it can benefit medicine.
Bone density: The amount of calcium and other minerals inside a section of bone. Strong bones contain a dense framework of protein strands coated with calcium. This support system thins with age, lack of exercise and low intake of calcium and vitamin D, among other reasons. Low bone density increases fracture risk.
Caregiving: The assistance family, friends and professionals provide to those who are old, sick or otherwise unable to care for themselves. Caregiving can include buying groceries, cooking meals, cleaning, assistance with bathing or personal care, making and driving someone to medical appointments, dispensing medicine, helping someone get in or out of bed, and more.
Family health history: Information about your health and the health of your close relatives. Some diseases are genetic, so having one or more family members with certain diseases may raise your risk of one day developing those diseases, too. A family health history helps your health-care provider determine if you have a higher risk of developing heart disease, stroke or cancer, among many other health problems.
Magnetic resonance imaging (MRI): A large machine that uses powerful magnets and radio waves to see inside your body. Unlike an X-ray, MRI testing does not use radiation. If you undergo this test, you’ll lie on a narrow table that slides inside a tunnel-shaped scanner for about 30 to 60 minutes while health-care professionals watch from another room. If you feel anxious in small, enclosed spaces, ask your physician about an open MRI that is not as close to the body.
Medical power of attorney: A legal document that names a trusted person, chosen by you, who will make decisions about your medical care according to your wishes if you are unable to make them for yourself. This person is legally bound to do as you wish and can use your living will to help guide them.