The Ultimate Guide to Your Medical Records
What are medical records?
Medical records are your health history at each of your doctors, health systems, or other healthcare providers.
Why should you organize your medical records?
Getting your medical information together can be a major hassle. Whether you're moving across the country, switching jobs, health insurance, and primary care providers, or don't like your doctor and want a change - it's important to take your information with you. This enables you and your doctor to catch the bigger trends with your health and better understand any future health issue you may have.
How else will you know if you're due for a tetanus shot or remember the name of the medication you took that finally got rid of that migraine?
We're breaking it down by:
Ways to Get Information
Patient Portal
Medical providers in the United States are required to give you access to your medical record online. These accounts are typically called patient portals. When you see a new doctor, they may have you set one up before, during, or immediately after your visit.
If you've seen a doctor and don't have a patient portal, you can visit their website to learn how to set up your account. You may be able to set it up online, but you might have to call or receive an "activation code" in the mail. The set-up process varies based on an organization's policies, not based on regulations.
Patient portal requirements are true for most medical specialties but do not apply to mental health, dentistry, or chiropractic care in the same way.
Additionally, patient portals are not required to give you all types of medical information. See "Types of Information" below for more details on what kind of information appears in a patient portal vs. what information you can only get via Release of Information Request.
Release of Information Request
A Release of Information (ROI) request is a formal, legal document requesting a hospital, health system, or doctor to release your medical records.
This documentation is required to release your medical records to another doctor, your life or health insurance, the military, or you directly.
These forms ask for detail about the type of information you'd like released. This is because information may be stored differently, depending on the type or when it was recorded.
With Another Doctor
Sometimes there are a few other pathways that doctors can use to get your information. If doctors use similar pieces of software to document your care, they may be able to share information easily. This information's types and format can be limited, but it is often an easier and faster way for them to get a sense of your medical history.
Some doctors or health systems will have you sign a HIPAA consent form and use that consent to request information from another health system or physician. While this is nice because they do the hard work for you, it may mean that a new doctor you are seeing won't have access to your medical history for your first appointment.
Types of Information
Lab Test Results
available via patient portal
if performed by an external lab, available via an online account with that lab (eg LabCorp, Quest)
typically easily released with a Release of Information Request
Medication Orders, Prescriptions
available via patient portal
if dispensed by an external pharmacy (ex: CVS, Walgreens, Duane Reade), then prescription information is also available on an online account with the pharmacy
typically easily released with a Release of Information Request
Vaccination / Immunization
available via patient portal
if given before the doctor recorded information on the computer, may only be available via Release of Information Request
typically easily released with a Release of Information Request
Diagnoses
available via patient portal
typically easily released with a Release of Information Request
this excludes mental health diagnoses, which are governed by different regulations and are not always released to patients
Allergies
available via patient portal
if officially diagnosed (ex: by an allergist), may appear with diagnoses in the medical record
often patient-reported
typically easily released with a Release of Information Request
Doctor's Notes
typically not available via patient portal
can be released with a Release of Information Request
Imaging Test Results
result reports (the written part) typically available via patient portal
result reports typically easily released with a Release of Information Request
raw images are typically not available via patient portal
raw images may require a separate Release of Information Request process, may be delivered via CD, may cost a significant amount of money
Types of Facilities
Primary Care
Your primary care doctor (aka general practitioner, internist... or just "the doctor") most likely documents your care on the computer and should have a patient portal available for you to see your information online. If you see a doctor who isn't part of a larger practice or organization (aka a single doctor practice), they may still use paper and not have a patient portal available.
Specialty Care
Like primary care doctors, specialists may be part of an independent practice or a larger health system. If your specialist and primary care doctor are part of the same healthcare organization, then they probably share information readily and document it in the same system. That system would give you access to both primary and specialty care from the same patient portal.
However, if your specialist is part of a different organization, then they'll document your care differently, may have a harder time sharing information with other doctors you see and may have a different patient portal account for you to set up.
Have multiple patient portals? Sign up for Wingspan Health to bring all of that information into one easy place.
Urgent Care
Urgent care facilities can be standalone centers (not affiliated with a larger organization) or affiliated with hospitals or medical groups. Because the software needed to run an urgent care facility is different from the software needed in a hospital or primary care office, you may find that an urgent care facility affiliated with an organization still has a separate patient portal.
Emergency Room
Emergency rooms and their affiliated hospitals almost always use the same software and provide information to you via a single patient portal. This is helpful if you are admitted to the hospital through the ER and want to see all of the information associated with your hospital stay in one place.
When taken to the emergency department in an ambulance, you can’t control which hospital you go to. You may find yourself at a hospital emergency room not affiliated with the organization you typically go to. This makes it harder for the ER doctors to see your medical history when you arrive -- and makes it harder for your primary care doctors to see what happened to you in the ER.
At an emergency room not affiliated with your main doctor? Make sure to ask for copies of your records --- or set up a patient portal --- before you are discharged so you can help your providers coordinate.
Hospital Care
Typically all care received within a hospital is documented in the same primary system. The information about your care should flow freely between the doctors and other providers caring for you, even as you switch departments or as staff switches shifts.
There are a couple of exceptions: in small, rural hospitals, emergency departments’ documentation is split from inpatient documentation. This (annoyingly) is primarily for billing reasons. But if you find yourself in the emergency room of a small rural hospital and are they admitted to an inpatient bed - you may need to log into two different patient portals to see a full record of that stay.
L&D care
You may choose to deliver a baby out of a hospital's Labor & Delivery (L&D) department, a Birthing Clinic affiliated with a hospital, or at home with a midwife. All of these care providers are required to keep detailed records of the birthing process and are required to share that information with you.
Obstetric care and delivery are some of the most highly regulated care. Obstetric physicians must keep records for a minimum of 18 years and are even liable to be sued for medical malpractice for that entire time.
We highly recommend getting copies of birth records if Mom or Baby has any future complications related to the birthing process. We will be developing a separate, in-depth guide around medical records in perinatal care.
Outpatient or Same-Day Surgery
If you're receiving a surgery where you'll go home on the same day, you may get that care from a couple of different types of facilities - all with different ways to access your medical information.
A same-day surgery center may be freestanding but affiliated with a hospital. It could also be a department inside of a hospital building. Either way, surgical centers affiliated with a larger hospital system typically use the same documentation systems as the rest of the hospital and provide you access to those records via a single patient portal. This can vary, especially if the surgical center was previously affiliated with a different organization (through a hospital merger or acquisition).
Fully free-standing outpatient surgical centers affiliated with a hospital will have their own documentation system and patient portal. If the center is affiliated with your regular primary care doctor – but not a hospital – it's likely that the surgery records would be separate from the records of your typical doctor's care. Why? The software needed to record surgeries is very different than the software needed to document regular clinic care.
To summarize, there are a lot of ways information may be divided up when receiving outpatient surgery. Be sure to ask the easiest way to see your medical history and sign up for any available patient portals!
Minute Clinic or Retail Care
Like CVS's minute clinic, retail clinics provide a smaller number of services in convenient locations that are typically easier to schedule. You may get a flu shot, screening, or other types of care at one of these places. They are generally required to give you online access to your information.
Been to a Minute Clinic or received Retail Care? Don't lose those records! Sign up for Wingspan Health to link your minute clinic medical information with your medical records from your normal doctors.
Online Doctors, Telehealth, Consumer Prescriptions
Telehealth records are typically separate from any other medical records you may have. Telehealth physicians don't have access to information from your primary care doctor, specialty care, or hospitalizations.
Consumer websites or products that provide prescription medication or lab tests without a need for an in-person appointment also store information separately. These products are not governed by the same regulations as most doctors’ offices, and therefore don't need to provide you access to the same kind of patient portal. However, you should have an online account for each of these services.
Want to link your consumer prescriptions and test results with your main medical information? Wingspan Health can do it! Otherwise, it can be hard to see a full picture of your health.
Examples of Consumer Health Services: Curology, Hims, Hers, Roman, Nurx, The Pill Club, Modern Fertility
Segments of Time
Within the last year
If you've seen a doctor within the last year, you're in good shape. Make sure you're set up with a patient portal to access your information online.
Within the last 5 years
If you've seen a doctor within the last five years, you should be able to get access to your medical information online via their patient portal.
About 5 years ago (2014) was when most of the last hospitals, health systems, and doctors switched to using software (instead of paper) to document your care.
Earlier in your life
The longer ago you received medical care, the more difficult it will be to retrieve your medical information. This is for a few reasons.
Doctors are only required to keep medical records for a certain number of years. The specific amount of time varies based on their specialty.
If you're in your 40s, even if your pediatrician is still practicing, they probably don't have your vaccination history.
When healthcare providers switched to electronic documentation, they left the old records on paper. That means that your medical information from more than 5-8 years ago is most likely on paper, in a box, in a storage facility.
Storing paper is expensive and annoying, so most healthcare organizations have tried to safely discard these records as soon as they were legally able to.
What now?
Ultimately, getting a full picture of your health from your medical records is up to you. You can either do a little bit of work (sign up for patient portals) when you switch doctors, or you can do a lot of work (print, sign, and mail forms) later down the line with more time pressure.
We recommend signing up for all available patient portals and syncing them with Wingspan Health.
This gets all of your medical records in one place. And unlike your doctors, we won't start deleting your information when it gets old.
Remember: Doctors document your care for legal and billing records. It's up to you to manage your medical history.
About Wingspan Health
Wingspan Health is a healthcare technology company that believes that quality healthcare should be accessible for everyone.
Our tool helps you understand your health by organizing your medical information in one place – from all of your patient portal accounts at each of your healthcare providers.
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