Building Your Medical Record File

Start with the documents that doctors ask for most: pathology reports with any addendums, imaging reports, and the image files themselves. Add operative and procedure notes, discharge summaries, lab results, a medication list and a list of allergies. Include treatment summaries with drug names and dates. Keep contact information for every doctor and facility. A short work history summary, listing employers, job sites, military service and years, is worth keeping in the same place because both doctors and case reviewers may need it. A list of dates for every procedure and hospital stay helps specialists understand your timeline quickly.

A sturdy binder with labeled tabs works well for many families, especially for bringing to appointments. Digital copies are easier to share and less likely to be lost. Patient portals often let you download reports as PDFs, and many imaging centers provide images through secure links or discs. Consider keeping a scanned copy of everything in a folder on a computer or secure cloud account, with file names that start with the date. Tell a trusted family member where the file is and how to access it. Update the file after each visit.

Under federal law, you have a right to access your medical records, and providers must respond within set timeframes. Ask each facility's medical records or health information department for the request form. Be specific about what you need, such as the complete pathology report including addendums, rather than asking for everything. Pathology slides and tissue blocks are requested separately from paper records, usually through the pathology department. Keep a note of what you requested and when, and follow up if nothing arrives. Some facilities charge reasonable copying fees, and electronic copies are often faster. If a request stalls, the facility's privacy officer can help resolve it.

1. 1

   Set up one binder or digital folder and organize documents by type and date.

2. 2

   Download available reports from each patient portal you have access to.

3. 3

   Submit written record requests to facilities that do not have online access.

4. 4

   Share the file's location and access details with one trusted family member.