A Paper Chase Through the Maze of Your Medical Past

Part of being an informed health care consumer means knowing as much as possible about your medical history. And that includes being familiar with the paper trail of your care, the medical record.

You may have more at stake than just being fully informed. What goes into your record over the years may influence your ability to get medical insurance and qualify for life insurance, and may affect even the way your doctors treat you.

Basically, the record of your health history, diagnoses, treatment, test results and hospitalizations for physical or mental illnesses belongs to the doctor or hospital that took it. But the information is yours too. You have a right to examine it and obtain copies.

If you encounter problems getting access to your medical charts, the law is on your side.

Twenty-six states, including California, have laws guaranteeing you the right to access your medical files. Although the other 24 states don’t have specific laws, patients have the right to see their files, says Charles Inlander, founder of the People’s Medical Society, a consumer advocacy organization. “You cannot be denied the information that’s in your record,” he says.

Your medical records consist of files from all the doctors you have visited and hospitals where you’ve been treated. If you’ve ever changed doctors, your records probably do not reside in a single place but are spread among many sites.

Traditionally, doctors haven’t seen the need to share the details. But as patients switch doctors and health plans more frequently, they increasingly want to know what’s in their records.

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Specific situations may send patients in search of particular records. They may be seeking a second opinion and need a copy of their diagnosis and test results to show a new doctor. Those applying for health or life insurance may want to see how--and whether--their doctors have documented medical conditions. If a patient suspects inadequate care, they may want the written record of what has, and hasn’t, been done.

California law requires that a doctor or hospital allow you to review your medical records within five days after a request is made. If you ask for photocopies, they have 15 days to get them to you. You pay the copying fees.

California sets a 25-cent-per-page maximum on copying charges. Doctors’ offices and hospitals also may bill you for the labor involved, typically $10 to $20, depending on the number of pages.

Once you get hold of the records, the next step is trying to decipher them. If parts of the record, such as medical terminology, abbreviations or the handwriting, are unclear, you can ask to discuss them with your doctor--but that may be easier said than done.

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Unfortunately, “there isn’t in law a mandate that your doctor tell you what [the medical record] means,” says Peter Lee, executive director of the Center for Health Care Rights, a consumer group in Los Angeles. “Many doctors have an incredible time crunch. They don’t have time to walk you through and translate.” Or they might not want to be bothered, especially in cases where the quality of care has been an issue between patient and doctor, and the physician may be worried about a malpractice claim.

If you are trying to decipher the medical record yourself, Lee suggests consulting health reference books or seeking credible information on the Internet, such as Web sites produced by a major academic medical center. Yet, despite the best efforts, there can still be peril in having a layperson read a medical record.

Lee described a situation he heard about recently in which a patient who was reviewing her medical file was stunned to see the abbreviation “SOB.” Assuming the worst, she wrote an angry letter to her doctor. It turns out that “SOB” was no reflection on her personality: It simply stood for “shortness of breath.”

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Getting access to medical records while you or a family member is in the hospital can be especially tricky. No longer are medical charts kept at the foot of the bed, as in the old TV doctor shows. Instead, they are typically kept at the nurse’s station, which can be intimidating for some patients.

But not all hospitals are the same. At the 33 hospitals and health care centers affiliated with Planetree Inc., a Derby, Conn., consulting company that tries to “personalize, humanize and demystify” the often cold and institutional environment of hospitals, patients and their families are encouraged to take charge of their health, says executive director Michael Gaeta. One way this is accomplished is by placing the patients’ charts in the hospital room or with nurses, where “the chart becomes available to the patient to not only read, but to write in if they want to make some comments.”

In more traditional hospitals, Inlander, of People’s Medical Society, suggests bringing up the subject before you’re admitted. “Tell the doctor you’d like copies of the record,” he advises. “Negotiate that upfront.”

Even when you’re aware of what should be in your record, it’s hard to know if the complete file has been turned over to you. The hospital record has documents that exist apart from your chart, like pharmacy records and billing records.

Inlander recommends that people keep their own running medical record and regularly review medical files. He suggests keeping a list of illnesses, treatments and prescription medications (and any adverse reactions) along with the most complete family medical history you can compile.

Having such information on hand also protects you, since medical documents aren’t retained forever. Although every state has its own statute on how long medical records must be retained, doctors usually can purge patient records after five to 10 years. So if you’re after your old vaccination records, you may be out of luck.

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There are times when it is especially important to get hold of your medical records, such as when you move to a new city. Your records should move with you.

If you’re having trouble getting documents from a hospital or doctor, suggests Inlander, try to find a sympathetic doctor who can request the record on your behalf.

In rare instances, a patient must resort to legal action to force a doctor or hospital to turn over records.

Deborah David, a Los Angeles plaintiffs’ attorney who handles medical malpractice cases, recommends learning as much as you can about hospital procedures and policies. An unknowing patient who requests copies of the record may receive a few typewritten pages that represent a fraction of what’s relevant, she says. For example, there are preoperative and postoperative reports, anesthesiology records, nurses’ notes, doctors’ notes and medication records.

She’s particularly concerned about protecting access to medical records for patients who may have encountered problems with their medical group or health insurance plans. Those patients are trying to get sensitive documents from the same organization that is providing them with continuing medical services.

Sometimes, if the health plan or doctor knows legal action is afoot, “they don’t treat the patient the same way,” she says. “I often tell patients to march on down to the medical records office and say they want the records because they want a second opinion, which isn’t entirely untrue, because what the lawyer is going to do is get a second opinion.”