How To Manage Health Records And Doctor Relationships

A Doctor’s Perspective

Your doctor, especially a primary care doctor, or the first specialist you see for a problem, has been with you during the entire course of a problem (during flare- ups, etc), and he /she has reviewed you from the starting point of symptoms. If you are not happy with your doctor for one reason or the other or have continuing problems (as some of these patients do), please think twice before you switch doctors. They have done the most important or essential testing. If you must go to a different doctor, please take your records with you, the clinic notes, labs, xrays, procedure reports, etc.

Make this a rule if you are moving out of town or out of country, because it is not always easy to get these records from your previous doctor. It may cause unnecessary delay in your diagnosis or treatment. It may cause repetition of tests as well.

Even with a complete report in hand (especially in cases of inflammation of the colon), it is somewhat difficult for a physician to know the severity of the disease based on someone else’s description, often depending on how detailed their report is. Physician techniques for reporting and sample taking from are likely going to vary. So, sometimes tests may need to be repeated, but first-hand information of a physician's own testing and reporting has its own merits. Similarly, when seeing someone for a second opinion, the doctor is giving an opinion of another doctor’s evaluation.

The same rule applies to hospital visits. This is more important for those patients who have several complicated medical problems that require frequent hospitalizations. Try not to go to a different hospital every time, although there may be certain situations (emergencies) when you go to the nearest hospital. Physicians appreciate having all of a patient’s records at one hospital.

Several points to consider when seeking hospital treatment are:

1. It takes time and effort to obtain records from another institution, and these attempts are not always successful. Your doctor might not always get all the information needed, depending on how thorough the medical records clerk on the other side is.

2. It delays treatment and may cause repetition of tests if multiple hospitals must be contacted for records.

3. It is best to call your doctor’s office first to see if they have some advice for you that may prevent you from going to the hospital. This does not apply in an emergency.

4. Find out which hospital your doctor works with. They may only have privileges to some hospitals.

5. Always go to one hospital, as they will have the records of your previous testing and what happened in the last hospitalization which is important information for your care.

6. When you are ready to be discharged, ask your attending physician to send a copy of the discharge summary to all the doctors involved in your care – your primary care doctor, your cardiologist or gastroenterologist, depending on the current problem.

7. Always take your discharge papers to any doctors seen afterwards for continued treatment of the problem - while it is not everything, it will at least give that doctor a list of medications you were sent home on. It is the patient’s responsibility to follow-up after discharge, to continue care, and to prevent it from happening again.

8. Always keep an accurate and updated list of medications with dosages with you – useful when you see a doctor or go to a hospital. It is best if it’s typed and has names of medications (brand name/ generic). Complete the list with your pharmacy and emergency contact information, and keep it in your wallet.

9. There are apps available for medical maintenance, but some patients prefer bringing a typed list of:

• medical problems – caring physicians for each problem
• medications
• allergies
• procedures done -surgeries, colonoscopies, etc.
• family history

It is not uncommon to overreact when reviewing your own actual reports – lab, xray etc. Reading the fine print, then micro-analyzing every minute detail, can lead some patients to attempt to self-diagnose and/or panic over the unknowns. This happens at times, and it is for these reasons that we advise against trying to read and interpret your own records.

Patients should, instead, ask the doctor that ordered the test to discuss results, any concerning findings, and the follow-up exams, if needed. Patients should trust that doctor to stress the important facts and ignore the incidental findings.

The most important component of medical care is the communication that you have between yourself and your doctor. If you are unhappy with treatment, tell them so, but attempt to resolve issues first before choosing to shop around for another doctor. Not only will this effort improve your relationship with your doctor, it will prevent your medical records from being sprinkled all over your hometown’s doctors offices.