How to Organize Personal Medical Records
Easy Way to Track Medical Treatments and Billings
Feb 5, 2009
Even healthy people often see more than one doctor a year, take one or more medications, and are given one or more routine screening tests. Patients with on-going conditions such as cancer or heart disease see an overwhelming number of doctors and technicians. To keep track of medical treatment, medications and billings, create a set of personal medical records. Start by buying a three-ring binder with section dividers, and gather together whatever medical papers are on hand.
Organize Medical Information in Sections
Type a table of contents page for the front of the binder. There is no right way to organize the information, but the divisions listed below work for most people. Add additional sections to suit specific circumstances.
Section 1: Contact information for Doctors and Clinics
Keep a running list of all medical service providers, including dentists, eye doctors and clinics where lab tests are performed. As a minimum, include:
- Name and specialty
- Address
- Phone number
- Fax number
Section 2: Summary of Doctor Visits and Tests
Create a running list of office visits on a sheet with three columns for:
- The Date
- The Doctor’s name
- A few words about the nature of the visit.
This is just a chronology of visits for easy reference. The detailed account of the visit is kept in the next section.
Section 3: Notes from the Doctor Visit
This section is more extensive than the summary. It is a place to record what the doctor said. If possible, take someone to the appointment who can take notes for you. If that is not possible, immediately after the office visit write a summary. If details are foggy, call the doctor's office for clarification. These records can be subdivided into sections by doctor, or kept chronologically.
Section 4: Copies of Medical Tests
Most doctors send copies of medical test results to their patients. If not, contact the doctor’s office and ask for a copy. Keep test results in chronological order.
Section 5: List of Prescription and Over the Counter Medications and Supplements
Create a list of all medications and update regularly. Include everything that is regularly taken. Use four columns to record:
- Date began taking the medication
- Name of the medication or supplement and the dosage (ex. Calcium 500mg. x3 per day)
- Reason for taking
- Any side effects or problems
Section 6: Billing and Insurance Papers
As insurance papers come in, collate them with the corresponding bill and mark them as paid or pending. Compare the bills against summary of office visits to protect against billing errors.
Section 7: Family History
This section is optional, but most doctors want a family history from new patients, so having it written down prevents errors and omissions.
Section 8: Medical Articles
Medical advice is everywhere these days, some of it is of dubious value. Keep relevant articles in this section and discuss them with the doctor.
Make sure the binder has your name and address on it, then take the binder to all medical appointments, and keep it updated. Anyone being treated for a chronic condition should tell family members and friends about their binder, and where it is kept. In the event of a medical emergency, doctors will have access to relevant information without waiting for medical records to be forwarded.
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