November 20, 2018
MEDICAL RECORD CONCEPT

Why You Should Create a Personal Health Record

by David Ansley  

Have you ever struggled to answer questions from your doctor about your health history because you can’t recall certain details, such as dates or tests results? If so, keeping a personal health record (PHR) and bringing all or part of it with you to your appointments might serve you well. You can use a PHR to keep track of your health and make informed health care decisions with your doctor, who can also benefit from reviewing your PHR, especially if it contains information he or she doesn’t have immediate access to.

A PHR is a broad view of your medical history that you personally compile. It’s different from your doctors’ medical records or electronic health records (EHRs), which are created by your health care providers. A PHR is created and managed solely by you. You can combine records from all your health care providers (even those not originally in compatible formats) and add personal notes about your health. And you’re able to keep your records in one convenient place.

Some health insurers, health systems, and private companies, such as Microsoft’s HealthVault and WebMD’s Health Manager, offer web-based services or smartphone apps where you can store your PHR in a private online account. However, private sites are not subject to federal privacy laws and have their own privacy policies, which you should read carefully.

If you’re not comfortable with storing your health records on a website, you can keep them on your computer or a password-protected USB drive (which you can share with your providers or family members) or file them in a three-ring binder.

Where to start

Begin organizing your PHR by gathering any documents you have at home that are related to your health care. If you have access to any online patient portals (password-protected websites that contain your EHRs and are controlled by your health care providers), you can download the documents or print them to file in your binder. You can request copies of your records by contacting your doctors’ offices or simply asking for copies at your next visit. When you have tests done, ask the office staff to send you copies of the results. Some offices can provide records either digitally, such as PDFs, or on paper.

If you’d like to use a form to guide you instead of starting from scratch, you can download blank forms to complete and include in your PHR. The forms are available from the American Health Information Management Association.

A PHR checklist

Try to include the following information in your PHR:

  • The names, full addresses, and contact information for all your doctors, pharmacists, and other health care providers
  • The names of your current prescription and nonprescription medications (include dosages, frequencies, and other details, such as before or after meals) as well as any vitamins, supplements, or herbal products
  • The names of past medications or supplements that you recently stopped taking
  • A list of any allergies or sensitivities, such as to drugs, foods, plants, pollen, animals, and materials such as latex or nickel
  • Your personal health history, including all current conditions and any past chronic conditions, major illnesses, and injuries, specifying the date of each diagnosis, and all past and current treatments.
  • Your family health history (include parents, siblings, and grandparents)
  • Copies of your paper and electronic health records
  • Your blood pressure, body mass index (or height and weight), waist circumference, cholesterol, and blood sugar numbers as well as the results of any other lab work, such as complete blood counts or urine tests
  • Any medical devices you use, such as an implantable cardioverter defibrillator, an insulin pump, or a continuous positive airway pressure (CPAP) device
  • Patient instructions or records of service from all your health care providers and your own notes summing up or commenting on your visit
  • Your doctor’s clinical notes or discharge summaries from recent clinic visits and hospitalizations (often available on a patient portal)
  • Dates and outcomes of any procedures or surgeries you’ve undergone
  • Results of screenings, such as bone mineral density exams, mammograms, and colonoscopies
  • Results of imaging tests, such as X-rays, ultrasounds, computed tomography (CT) scans, and magnetic resonance imaging (MRI) studies
  • Results of any other diagnostic tests, such as tissue biopsies, pulmonary function tests, and EKGs
  • Dates of and information about any hospitalizations and hospital discharge summaries
  • A list of immunizations and their dates
  • Dates of, reasons for, and outcomes of visits to physician and nonphysician specialists
  • All Medicare information and any health insurance policies, including their full addresses, contact information, and policy numbers
  • Copies of legal documents, such as advance directives, living wills, medical powers of attorney, consent forms, or organ donation authorizations
  • Your emergency contacts

This article first appeared in the October 2018 issue of UC Berkeley Health After 50.