How to make and archive personal medical records

It a must for all persons in this earth to establish and develop a system of making, keeping, and maintaining personal medical records and to ensure their accessibility at all times.  It is important to have the personal medical records readily accessible as it has impact on the timeliness and correctness of the decision-making in health management, particularly during emergencies.  The personal medical records are also needed for insurance purposes as well as for international travel and migration.

How to make a personal medical records

Personal medical records are those medical records constructed, archived and made readily accessible when needed by the patient himself or assisted by somebody, either a guardian or by a physician.

First of all, an individual or his guardian will have to initiate this after realizing its importance.

Second is how to do it.

My personal general suggestions are:

  1. To construct a complete personal medical record from birth till current year / month.
    • The following data and information should be included:
      • Vaccination / immunization records
      • Past significant medical illnesses
        •  (Significant means those that have caused permanent or temporary physical and mental disability; hospitalizations; operations; and medical procedures even outside the hospitals and operating room.)
      • Current health status and significant concerns (significant – same concept as above)
  1. If a complete personal medical record cannot be constructed right away because of loss of records and inability to access old records (eg. immunization and past records), focus on the current health status and significant concerns. Overtime, try to retrieve the old records (best efforts) to complete the personal medical records as much as possible.  Go back to the physicians who made the past and current treatment and the hospitals and clinics where past and current treatment were done to get the past and current medical records.
  2. Ask a physician to collate all the past medical records to come out with the current health status and concerns. Note the individual or the guardian will have to submit to the physician as many records as can be retrieved and undergo interview and physical examination.

How to keep, file and archive the personal medical records

Presenting forms of medical records

Medical records can be paper documents containing the medical reports; x-ray plates; other imaging plates; medical tracings; photos; video recordings; audio-recordings; etc.

Medical records come in the form of two media: print and non-print. Examples of print medical reports are those printed on paper.  Examples of non-print medical reports are the digitalized medical reports; x-ray plates; other imaging plates; medical tracings; photos; video recordings; audio-recordings; etc.

How to keep

For print medical records, one can use fastener folders; clearbooks; cardboard envelop folders; and plastic envelop folders to keep and file.

For non-print medical records, except for digitalized medical reports stored in computers and Internet, one can use cardboard envelop folders and plastic envelop folders for small quantities.  One may have to use a bigger container box for the bulky medical records as well as big quantity.

How to file

Medical records are filed in several ways:

  1. Based on the three categories of medical records (immunization; past medical illnesses; and current health status and concerns).
  2. Based on the chronology of medical records.
  3. Based on the types of medical records (blood tests; urine tests; x-rays; etc.) [which should be filed chronologically if indicated].

How to safekeep and have a backup

Medical records should be kept in a safe place at home. They can be kept private if needed.

Medical records must have a backup copy as much as possible, either print photocopied or digitalized, preferably, in the latter form.  The digital copy can be stored in personal computers; in USB; or in the Internet.

How to make the personal medical records readily accessible when needed

First, the personal medical records should be complete as much as possible.

Second, the personal medical records are filed properly.

Third, the personal medical records can be presented to the physicians who need to see them on demand, both the print and non-print medical records.  The medical records can be presented to the physicians as kept and filed in the containing folders.  Or, the digitalized medical records in an USB or in the Internet can be presented to the physicians who need to see them.

Quality parameter of personal medical records

  • Complete
  • Filed systematically
  • Collated and summarized properly and adequately at planned intervals (say every year or 2 years)
  • Easily retrievable

 Advices:

  • Start constructing or reconstructing  your personal medical records.
  • Always ask for copies of your medical records from your physicians; clinics; laboratories; radiology centers; and hospitals you went for consult and treatment.
  • Never leave your only copy of medical records to the physicians you are consulting at a clinic.
  • Always bring your past medical records (at least the recent ones) every time you consult a physician in a clinic; radiology centers; and hospitals.

Link:

ROJoson’s Project Patient Medical Records – Initial Conceptualization

https://rojosonmedicalclinic.wordpress.com/2014/03/02/rojosons-project-patient-medical-records-initial-conceptualization

ROJ-TPOR@16feb17;24

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