How to Read Your Health Record

The information contained within your health record belongs to you! Make sure it is complete, up to date, and accurate. Your health record is the primary way your healthcare providers communicate your care and ensure your constant and consistent care. It also serves as a legal document describing your care to your health insurance company. Knowing what is in your health record increases awareness and understanding of your health status, enables you to have better conversations with your care providers, and lets you take a more involved role in your treatment decisions.

Federal laws protect the privacy of your medical information and allow you to view, request changes to, and obtain copies of medical documents collected and kept about you. Your healthcare organization must comply with these requirements. Take the following steps to obtain and read a copy of your health records:

  • Contact your doctor’s office or the Health Information Management Department of the hospital or facility where you have been a patient.
  • Tell the receptionist that you would like to obtain a copy of your health record. You will receive form(s) to fill out that ask for identifying information, including your name, date of hospitalization, address, and other pertinent information.
  • You may be asked for your driver’s license to verify your identity.
  • The hospital’s privacy policies regarding release of information will be provided to you when obtaining copies of your record.
  • You may have to specify an exact report(s) in your record, or simply request an “abstract” of the health record, which typically includes the dictated reports.
  • By law, the fee can only include the cost of copying, including supplies and labor as well as postage if you request the copy to be mailed.
  • Copies of your health record will be made by the facility’s staff or by a contracted copy service.
  • Unless specified otherwise, the copies will be mailed to your home. Federal law states that healthcare providers have up to 60 days to fulfill a request for records.

The information in your health record is important. Review the following in your record and make sure they are accurate and complete:

  • Contact and Identification Information
  • Correct Listing of Allergies to Medications and Foods
  • Correct Dosage and Administration of Medications
  • Accuracy of Family History
  • Accuracy of Past Medical and Surgical History
  • Important Test Results
  • Immunizations and Dates
  • Discharge Instructions and Follow-up Plans
  • Emergency Contact Numbers
  • Living Will and Advance Directives
  • Health Insurance Information

AHDI_Logo_blueBrought to you by the Association for Healthcare Documentation Integrity on behalf of healthcare documentation specialists protecting the integrity of your health record.