Should you keep your own personal health record?
HealthSmart! Should you keep your own personal health record (Printable PDF, 117 KB)
You probably need a personal health record (PHR) if you:
- Travel a lot.
- Move frequently and change doctors.
- Have many medical problems.
- Have chronic pain or a chronic medical problem.
What is a personal health record?
A PHR is any organized system you maintain for documenting your own and your family members’ personal information, health conditions, medicines, health care providers, medical procedures, medical test results and special needs. Keeping a PHR is a great way to take responsibility for your health and medical care.
Different types of records can be stored in your PHR. Every time you visit a doctor or are hospitalized, documentation of your visit is put into a medical record. A medical record describes the care you received, test results, prescribed medicines, etc.
Obtaining a medical record at a later date can sometimes be difficult. A solution would be to ask for a record of what happened during your visit when you are leaving. Then you can add each item to your PHR immediately.
There are two basic types of PHRs: paper and electronic. Your PHR should be stored in a manner that is best for you.
- Paper PHRs – documents and files
- Electronic PHRs (ePHR) – on your computer, thumb drive or an online service.
To be useful when you need them, PHRs should be available at all times on paper, portable electronic media, on secure sites on the Internet or through a centralized electronic data repository. For those without access to the Internet or with weak computer skills, a paper PHR works very well. Often, access to electronic records can be a problem, especially when traveling in certain countries.
People who benefit most from PHRs
- Children with special health needs
- Patients with chronic medical problems
- Patients with multiple medical problems seeing two or more doctors
- Elderly patients who require frequent monitoring and evaluation.
- People living alone, so in case of an emergency a relative or friend can access relevant medical information.
Why should you keep your own records?
Keeping your own personal health records has many benefits for your health. First, they can help you interact better with your doctors, nurses, pharmacists and other providers. It is difficult for most people to remember exactly what treatments they have received throughout the years and exactly when they occurred. This can result in doctors repeating tests unnecessarily.
Use of your PHR can save you time and money and give your doctor information that can help show changes in your health status. Also, if you have several doctors, have moved somewhere new or just change doctors for any reason, your providers won’t have a complete up-to-date record on you. If you have your own records, you can help your doctor provide better, more coordinated care.
For those with a chronic illness, maintaining your own personal records can help track the symptoms and progress of your condition. You may be seeing several specialists, and a personal health record can help you keep your information in one place to be referenced by you and your doctors.
In the event of an emergency, having these records is very beneficial. People who keep a PHR are generally more empowered and active in managing their care. A PHR also promotes safety, as individuals can verify health data to prevent errors.
What to keep in your PHR
- Your name
First, middle, last name and the last name you had at birth, if different.
- Your birth date
- Emergency contacts
Include their contact information, land and cell phones.
- Current date
So whoever is looking through your PHR will know when it was last updated.
- Health insurance information
Include your health insurance company’s name and contact information. Since identity theft is a concern, include your group number but not your individual policy number. You’ll want to have this available separately. If you have both primary and secondary insurance, be sure to include both and note which is which.
- Family history
Include any medical information of blood relatives, particularly your parents, grandparents, siblings and children, as their history might apply to you genetically.
For each person, include as much information as you know, such as major illnesses. If the person has died, include the age they were when they died and the cause of their death.
This master list of the important components of family history will help you record exactly the information your health care provider needs.
- Advance directives
Include scanned copies of your advance directives, which are legal documents that allow you to convey your decisions about end-of-life care ahead of time. They might include “do not resuscitate” (DNR) orders, a living will, a health care proxy and information about organ donation.
For more information on advance directives and how to create them, visit www.nlm.nih gov/medlineplus/advancedirectives.html.
In Kentucky, you can get information on living wills and medical powers of attorney through the Kentucky Attorney General’s Office. Call (502) 696-5300 or visit http://ag.ky.gov/civil/consumerprotection/livingwills/Pages/default.aspx.
- List of your doctors
Include cards from both current and past doctors (including dentist, dermatologist, optometrist or ophthalmologist, etc.) with addresses and phone numbers. It’s also helpful to note the medical problem they are addressing for you. This will give you an easy way to find numbers and addresses when you need them.
- Your health history, including:
- Current conditions and treatments
- Psychiatric conditions, if any, and treatments
- Past conditions, dates and treatments
- Past surgeries and dates. Include any adverse reactions you had to anesthesia, if applicable.
- Immunizations and dates
- A list of any allergies you have to medicine, food or anything else
You may also want to request copies of your medical records from each of your doctors and store these in your binder.
- Date and results of annual physical exams
- Include copies of all test results and any comments from your doctor.
File these so that the most current is first in your record.
List current as well as past medications.
- Any vitamins, herbal supplements and homeopathic remedies you are taking.
These can sometimes interact with prescribed medications, so it’s important to share this information with your doctors and include it in your PHR.
- Blank paper
Use this to jot down questions for your doctor, then refer to it during your appointment so you don’t leave something out. If a family member or friend accompanies you to your appointment, ask them to take notes about what the doctor says. Being a patient is stressful, and your companion may have an easier time understanding and remembering the doctor’s instructions than you would.
Privacy and storage
Once you’ve gotten your PHR started, it’s important to keep it private and safe. Consider storing your PHR in a fireproof safe, which will protect it from prying eyes as well as from natural disasters.
Be sure to let someone you trust, such as your spouse or adult child, know where your PHR is, in case you become ill or injured and cannot speak for yourself. In such situations, your PHR can be a lifesaver, as it will communicate details of your medical history that no one else may know.
Tips from other paper PHR users
- Put your PHR in a visible place where your spouse or family can find it in an emergency.
- Keep your PHR in a binder where you will see it each day – on your desk, etc. – so you will remember to update it regularly.
- Sons and daughters of elderly parents should be asked to keep their parents’ PHRs up to date and use them often to look up information.
- If a PHR binder or container is given to you, immediately collect the information you have kept in folders and drawers and take the time to organize it.
- Take the PHR with you when you visit the doctor and make notes. Insert letters, records, lab results, etc., right away when you get home.
- Billing questions often come up over medical care. Keep your statements and bills with the PHR so you can reference them when there is a question.
When taking your PHR to doctors’ appointments, remember to keep it with you (or with a trusted companion) at all times. Never leave your PHR unattended in a place where a stranger may access it.
Medical identity theft is an important consideration. Identity thieves may use your medical information to obtain care fraudulently and bill it to your insurance. For information on protecting yourself from medical identity theft, request the UK HealthCare HealthSmart! on Medical Identity Theft by calling (800) 333-8874 or (859) 257-1000.
Updating your PHR
Your PHR is only as helpful as it is complete. If it is missing information or out of date, it could cause more harm than good. For instance, if you are taking a new prescription, all of your doctors will need to be aware of it. So it’s important to keep the information complete and current.
To make sure your PHR stays up to date:
- Add information about doctor visits the same day you attend them.
- Regularly ask relatives about their health and add the information.
- Note new medication prescriptions and refills when you visit the pharmacy.
- Add copies of bills, test results and insurance information when you receive it.
- Mark a calendar for every three months to revisit your PHR and make sure it’s up to date.
Ways to keep your PHR
One way is a homemade version. Here’s a suggestion of what to include in your homemade version:
- A clear business card holder sheet
- Loose leaf paper to record the date you go to the doctor and what happens there.
Why did you go? What prescriptions did you receive? Tests? What diagnosis did you get? You can use the same paper to list any emergency contacts, personal information, etc.
Benefits of keeping a personal health record
A PHR can offer you and your doctor a more complete picture of your health because it includes information your current doctors may not have. Having your own PHR will also help save time. With a complete PHR, your doctors can simply review it and get everything they need to know quickly without extensive questions or calling your former doctor for answers.
A PHR can also save time and money in avoiding repeated tests or treatments. And when you change doctors, a PHR can be beneficial because it helps you provide your new doctor with a complete health history. A PHR can also ensure safety when it comes to your health. When you first visit a doctor you are usually given a form to fill out about your health history, prescriptions you’re taking or have taken, and past procedures and tests. A PHR helps you remember all of the details of your health and is a convenient way for the doctor to scan for details you’re not sure would be relevant.
PHRs can be very helpful in an emergency or a disaster management situation.
Call UK Health Connection at (859) 257-1000 or toll free (800) 333-8874 to make an appointment or request a referral. Visit us online at ukhealthcare.uky.edu.