3 Steps to Building a Personal Medical Record

August 25, 2016
Amy Thompson

A personal medical record is a compilation of all your medical information, including test results, treatment reports, and notes written by your health care team. While each office and facility keeps a record of your care, it’s important to have a complete file for your own use, so you can share it with a new doctor, review at home to better understand your treatment, or manage your health insurance claims, taxes, and other legal matters. Here is what to include, how to compile it, and the best ways to organize it and store it for safekeeping. 

Step 1. What to include

A complete personal medical record should include the following information:

  • Your diagnosis, including the specific cancer type and stage

  • Date you were diagnosed

  • Copies of diagnostic test results and pathology reports

  • Complete treatment information, such as chemotherapy drug names and doses, sites and doses of radiation therapy

  • Start and end dates for all treatments

  • Results of treatment and any complications or side effects

  • Information about palliative care, including medications for pain management, nausea, or other side effects

  • A schedule for follow-up care

  • Contact information for the doctors and treatment centers involved in your diagnosis and treatment, as well as others who have cared for you in the past, such as your family doctor

  • Dates and details of other major illnesses, chronic health conditions, and hospitalizations

  • Family medical history

  • Details of past physical exams, including cancer screening tests and immunizations

Step 2. How to compile your personal medical record

Keeping track of your medical records might feel like a huge task, but it’s worth it in the long run. ”share  The American Society of Clinical Oncology (ASCO) offers cancer treatment plans and summaries that can help keep track of information about your diagnosis and treatment.

Compiling this information on an ongoing basis will create a complete and easily accessible view of your health. Remember these strategies to help you collect the latest copies of your records:

  • When you have a diagnostic test or procedure, ask for a copy of the results or report

  • At each appointment, ask your doctor or nurse for a copy of anything new that’s been added to your file or electronic medical record

  • If you spent time in the hospital, ask for a copy of your records when you’re discharged

  • Keep copies of your medical bills and insurance claims as they occur

  • Talk to your doctor if you need help figuring out which records to include

  • If collecting this information feels overwhelming, ask your friends or family for help. While you have to sign off on any requests for personal medical information, they can fill out forms or make phone calls for you.

Step 3. Organizing and storing your personal medical record

There are different ways to organize your medical records. To help figure out what works best for you, talk to other cancer survivors about what they have done, or visit a local office supply store to see what sort of organizers are available. Here are a few options:

  • Use a filing cabinet, 3-ring binder, or desktop divider with individual folders

  • Store files on a computer, where you can scan and save documents or type up notes from an appointment

  • Store records online using an e-health tool; certain online records tools may be accessed, with permission, by doctors or family members

  • Organize your records by date or by categories, such as treatments, tests, doctor appointment, etc.

However you decide to store your personal medical record, be sure to keep them in a secure location, like a safe deposit box, fireproof home safe, or password-protected files. If you decide to use an online service, carefully check the security and confidentiality measures the company uses to protect your information. A family member or friend could also keep a copy in case of emergency. 

Get more tips for organizing your medical records.