Obtaining Your Medical Records
It is a good idea to have a copy of your medical records. For example, medical records are generally requested for a second opinion. However, the laws for obtaining records vary by state. Many states allow medical records to be released directly to the patient. Other states require that medical records be sent directly to the consulting physician.
The quickest way to obtain these records is from the doctor’s office. Copies of scans, pathology, operative, and consultation reports, as well as office visit records, are generally available from the doctor’s office. Your doctor may be able to access your scans electronically and copy them for you. There may be a charge for providing a copy of medical records.
A consulting physician may also need to see your actual scans, not just the written reports. If your doctor does not have the scans, call the hospital’s Radiology or Imaging Department where the scan was done. MRI, CT, fMRI, and PET scans can all be copied. Since there is a sizeable fee to copy scans, get a list of the exact scans needed. Be sure to have copies sent; never send an original through the mail.
Some hospitals store reports and scans in electronic, or digital, files. These files can be transferred electronically, copied onto a CD, or printed as traditional records. The consulting doctor can tell you which version is preferred.
Some consulting doctors (and some patients) ask for a second reading of the pathology report. To obtain your slides, call the Pathology Department of the hospital where the surgery was performed. Some slides can be copied. If they cannot be copied, ask if the hospital has a “paraffin block” sample of your tumor tissue. This is a larger piece of tissue, stored in a wax base, from which new slides may be created. Paraffin blocks, due to their size, are usually kept only a few years. Slides may be kept longer. Again, there may be a charge to duplicate or ship the pathology slides.
Some hospitals store reports and scans in electronic, or digital, files. These files can be transferred electronically, copied onto a CD, or printed as traditional records.
Written records of hospitalizations are kept in the Medical Records Department of the hospital for several years. Afterward, they may be copied into electronic files or otherwise archived.
Before providing copies of hospital records, the Medical Records Department will ask for personal information, including your birth date, social security number, and approximate dates of hospitalization. Some hospitals require your written authorization to release the records.
Find out if the records will be released to you or sent directly to the consulting doctor. If the records need to be picked up, find out where and when they will be available. If the records are to be forwarded, the doctor or hospital will need the consulting doctor’s name, address, and telephone number. Find out when the records will be sent and by what method. It may be best to have the records shipped by a company that has a tracking system for packages.
Finally, the consulting doctor should be alerted as to when the records will arrive. The doctor should be asked if he or she will provide the consultation by phone or if an appointment is required. The doctor will need enough time to appropriately review the records before rendering an opinion.
It’s tempting to read your medical records before sending them on to a consulting doctor. However, these records are written in technical medical terms. The words and terms may be new to you and may be alarming because they can be difficult to understand. Concerns about anything you find in the records should be discussed with your healthcare team.
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Reprinted with permission from TLC, Tips for Living and Coping, a monthly e-bulletin, September 2007, copyright ®2007, American Brain Tumor Association, www.abta.org.
This article was published in Coping® with Cancer magazine, January/February 2011.