Your Personal Health Records:
Why is your personal health information so important? Well, you never know when you will need it, but when you do need it, its generally for very important reasons. A more complete and accurate health profile will greatly improve the quality of your healthcare.
What is a Personal Health Record:
The PHR is a tool for collecting, tracking and sharing important up-to-date information about your health or the health of someone in your care. Using a PHR will assist in better health decisions and improve the quality of care by allowing access and use of information needed to communicate effectively with others about your healthcare.
- You are ultimately responsible for making decisions about your health.
- You should have access to your complete health information.
- Information in your PHR should be accurate, reliable, and complete.
- You should have control over how your health information is accessed, used, and disclosed.
- A PHR may be separate from and does not normally replace the legal medical record of any provider.
What does your Personal Health Record contain?
The specific content of your health record depends on the type of healthcare you have received. Listed below are documents common to most health records and additional documents that accompany hospital stays or surgery.
Reports Common to Most Health Records:
- Identification Sheet – A form originated at the time of registration or admission. This form lists your name, address, telephone number, insurance, and policy number.
- Problem List – A list of significant illnesses and operations you have had.
- Medication Record – A list of medicines prescribed or given to you. This form often lists any medication allergies you may have.
- History and Physical – A document that describes any major illnesses and surgeries you have had, any significant family history of disease, your health habits and current medications. It also states what the physician found when he or she examined you.
- Progress Notes – Notes made by the doctors, nurses, therapists, and social workers caring for you that reflect your response to treatment, their observations and plans for continued treatment.
- Consultation – An opinion about your condition made by a physician other than your primary care physician. Sometimes a consultation is performed because your physician would like the advice and counsel of another physician.
- Physician's Orders – Your physician's directions to other members of the healthcare team regarding your medications, tests, diets, and treatments.
- Imaging and X-ray Reports – Describe the findings of x-rays, mammograms, ultrasounds, and scans. The actual films are maintained in the radiology or imaging departments or on a computer.
- Lab Reports – Describe the results of tests conducted on body fluids. Common examples include a throat culture, urinalysis, cholesterol level, and complete blood count (CBC). Surprisingly, your health record does not usually contain your blood type. Blood typing is not part of routine lab work.
- Immunization Record – A form documenting immunizations given for disease such as polio, measles, mumps, rubella, and the flu. Parents should maintain a copy of their children's immunization records with other important papers.
- Consent and Authorization Forms – Copies of consents for admission, treatment, surgery, and release of information. (CLICK HERE TO DOWNLOAD)
How does a Personal Health Record work?:
A record is created every time you visit your physician, hospital, or another healthcare provider. This information is compiled into what is known as your medical or health record, which is protected under HIPAA privacy and security compliance. It is important to understand that PHRs—that are not part of a provider’s electronic health record—are not considered legal health records and therefore, are not HIPAA covered entities.
Chances are, you have lots of different medical records. You may see many different healthcare providers during your lifetime such as a family practitioner, an allergist, a specialist such as a cardiologist, and if necessary, a surgeon. Each of these providers compiles a separate file of information about you. In fact, even if your providers are all connected in the same health care facility or system, they may each keep a separate medical record for you and may not be aware of the other treatment you are receiving. This can lead to an incomplete and disconnected record of your health. A personal health record through Access Health Records compiles all of your records into one complete, secure and accessible electronic format.
Why should you keep a Personal Health Record?:
Your health information is scattered across many different providers and facilities. Keeping your own complete, updated and easily accessible health record means you can play a more active role in your healthcare. You wouldn’t write checks without keeping a check register. The same level of responsibility makes sense for your healthcare.
A patient’s own PHR offers a different perspective, showing all your health-related information. It can include any information that you think affects your health, including information that your doctor may not have, such as your exercise routines, dietary habits, or glucose levels if you are diabetic.
Also, the PHR is a critical tool that enables you to partner with your providers. It can reduce or eliminate duplicate procedures or processes, which saves healthcare dollars, your time, and the provider’s time. And the information you gather gives you knowledge that assists your preparation for appointments.
With your PHR, you can:
- Knowledgably discuss your health with healthcare providers
- Provide information to new caregivers
- Have easy access to your health information while traveling
- Access your information when your doctor's office is closed
- Record your progress toward specific health-related goals
- Refer to physician instructions, prescriptions, allergies, medications, insurance claims, and more.
- Track appointments, vaccinations, and numerous other wellness healthcare services
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