Keep It Together (Your Records, I Mean!)

I’ve served in two branches of the U.S. military: first in the Army, as a cavalry scout (which paid for college) and then in the Navy, as a physician. One lesson we learned early on was:

Always keep your medical records with you!

This makes sense in the military. Station changes are common, and your files won’t always arrive when you do. And even though we had an electronic medical records system (EMR), it often crashed (usually about 5pm Eastern time, when all the major facilities on the East Coast were trying to finish their charting and go home!) and had some odd quirks to it – as a doctor in Twentynine Palms, I found I could easily pull up records from Guam or Okinawa, but getting anything from San Diego (only three hours away) seemed beyond the pale.

In the Army, at least, we were required to have hard copies of our records, and had to bring them in to our battalion physicals for review. I never saw my First Sergeant cry until he showed up one year without his records and got to the vaccine station. The medic asked for his records, Top said he forgot them at home, and the medic just shook his head and started laying out one vaccine syringe after another. Top asked him what he was doing, and the medic calmly replied, “Without proof of your shot record, I have to give you all your shots today.”

As a physician in civilian life I am often confidently told by my patients their files from another hospital are “all on your computer there,” to which I have to explain, much to their surprise, that they aren’t.

The fact is that each hospital system has their own EMR. Granted there are some major platforms, like Epic and Athena, but even though two hospital systems may use the same platform, each hospital system maintains their own files separate from everyone else’s. Cleveland Clinic does not share its records with Steward Medical Group, and so forth. The reason for this is related to the ownership of those records.

‘So who owns my records?’ you may ask.

The general rule is that the records belong to the entity that created them, usually the doctor. This goes back to copyright law of intellectual property. If your doctor is employed by a group or hospital system, the employer claims ownership (unless they have a contract to the contrary). This actually makes sense, if your doctor decides to move to another area, but you plan on staying at the same clinic and just following up with the new provider. The entity then acts as a steward of your records and will not release them to another party without your written permission – even if that other party is yourself!

This usually isn’t a huge problem. These hospitals aren’t trying to hold your records hostage, they just want to respect the law. But it does involve an extra step to get your hands on them, and these entities are allowed to charge for copies and postage if you want them printed out for you. And it can take time to get them – a lot of time. Waiting for weeks, or even months, is not unheard of.

This becomes really important when a malpractice case comes up. Having to wait for records will delay preparation. Sometimes records come in in bits and pieces, some from here, some from there, and sometimes a facility won’t send everything all at once, for whatever reason. You might miss a statute of limitations deadline waiting for records. You might spend a lot of money thinking you have a case, only to find out at the eleventh hour that you don’t.

So what do you do? Keep files as you go!

Get copies of visits after you’ve seen your doctor, or have been to the hospital, or at regular intervals if you have a family member in a nursing home. If you’re not good at organizing, don’t worry. Sorting the records can be confusing and that’s what we’re here for. To be honest, you and I may have different ideas of how to organize records and that can make things harder to find. Your best bet is to just put everything in chronological order.

But be aware that the ‘After Visit Summary’ you get from your PCP, or the ‘Patient Discharge Instructions’ you get as you leave the hospital, are the barest surface of what was done. It’s only the info you as a patient need to know (it’s kind of like that old military idea of information being given on a ‘need to know basis’). Behind those documents are pages (sometimes hundreds) of labs, progress notes, imaging reports, assessments and other records that tell the actual story of what happened, and more importantly, why. This won’t be given to you unless you ask for them (with that signed release) and these are the records that you need to have with you. These are the records that give me an insight into what your doctors were thinking, the information they had available, when they had it, and what influenced their decisions.

With a current file of your records in hand you will be better prepared to handle any adverse events. It’s also not a bad idea to have even for something as simple as you moving to another area. Remember, sometimes it can take weeks for a hospital to respond to a records request, and you may need to see your new doctor before then. So keep it together!