Chances are you've probably run across patients or clients who simply can't remember their previous doctor's name. They have medical records, but they're not sure where they are. They know they've had a baseline mammogram, but they can't remember where or when. How many of us can remember when we had our last tetanus shot? Or what our last cholesterol numbers were?
Keeping track of medical information can sometimes be difficult, but the North Carolina Healthy Start Foundation has a new publication designed to help women keep their health information organized and up to date. My Health Journal (Mi Diario de Salud in Spanish) is designed to help women track their healthcare visits, record their medical test results, note questions to ask their doctor and set health goals. The journal also allows women to keep track of their reproductive health: methods of birth control, breast self-exam check and menstrual cycle.
Another important part of the journal is a place where women can keep a record of their family's health history. A recent U.S. Health and Human Services study found that 96 percent of Americans believe that knowing family history is important. Yet, the same survey found that less than one-third of Americans have ever tried to gather their family's health history.
Most of us know that we can reduce our risk of disease by eating a healthy diet, getting exercise, and not smoking. But how many of the women you see know that their family health history might be one of the strongest influences on their risk of developing cancer, diabetes, heart disease, or stroke? Even though no one can change their genetic makeup, knowing family health history can help people make the right decisions to reduce their risk of developing serious health problems. Women should be encouraged to learn about their family health history by asking questions and talking at family gatherings. Being aware of family health history is an important part of a lifelong wellness plan.
Many people might think of a "medical record" as something only doctors or nurses handle, but personal medical records can be very valuable to health providers especially during a visit. Times have changed and it's rare when a patient has a family doctor who has treated them since birth. Having a medical history conveniently in one place can help identify problem areas or medical conditions that could be life threatening.
My Health Journal is a great way for women to begin to take ownership of their personal healthcare information. It's also a helpful tool to guide dialogue and questions with providers during healthcare visits. The English and Spanish journals were produced by the RICHES Project (Resources in Communities Help Encourage Solutions) of the North Carolina Healthy Start Foundation through a grant from the North Carolina GlaxoSmithKline Foundation. Free copies of My Health Journal can be ordered (in bulk) on line at www.NCHealthyStart.org/catalog.
For your clients who are unfamiliar with medical records, it's important for them to know their legal rights. All hospitals and doctors' offices have a release form that they can use to request medical records. They also need to know that offices may only keep records for a certain amount of time as required by that state. The North Carolina Medical Board states, "Each physician has a duty on the request of a patient or the patient's representative to release a copy of the record in a timely manner to the patient or the patient's representative, unless the physician believes that such release would endanger the patient's life or cause harm to another person ....Physicians may charge a reasonable fee for the preparation and/or the photocopying of medical and other records." In most cases copies of records must be provided within 30 days of a request.
There are very strict privacy restrictions on the release of medical records. It's important for people to realize that even if they are a caregiver or immediate family member, they shouldn't assume to automatically have rights to the other person's medical information. To access another adult's information:
In case of lengthy or permanent incapacity, a legal guardian for the patient may be appointed through court proceedings. In that case, the legal guardian can access the patient's health records and decide who else can see them.
For Health Professionals and Community Groups