Organizing physician office records

physician office recordsYou would like to have your physician office records so you can be more informed about your condition, you have questions about your care, or you are changing doctors. It can be difficult to obtain the records of your physicians and may require persistence. In many states your doctor is required to fulfill a request for medical records in a specific time frame and may not withhold your records because of unpaid bills.

Here is what you can expect to find in your physician’s office records. Your records may not include all of these pieces.

1. Intake forms – a form you may be asked to fill out that gives details of your symptoms and health history
2. A problem list of your chronic conditions
3. Office notes that include your symptoms, the results of your examinations, and the treatment plan
4. Diagnostic test results of blood work, x-rays, MRIs, EKGs, CT scans and so on
5. Copies of hospital records such as histories and physicals, consultations, discharge summaries
6. Correspondence with insurance companies, other physicians, and so on
7. Consents for treatment
8. Records of other physicians and healthcare providers, such as home health nurses and physical therapists
9. Phone call logs or messages
10. Billing statements
11. Copies of your insurance card
12. Return to work statements (saying when you may be able to go back to work)

Use this list divide the records into these sections. It is usually easiest to organize them from the oldest record, such as the first office visit, to the most recent. Read your records. Is there anything missing or any misinformation (such as entries that refer to a different patient)? Make note of any terms or abbreviations that you do not understand and look them up using a medical dictionary online. The more you understand about your medical history, office records, and conditions, the easier it will be to ask questions.

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