It can be difficult to decipher your medical records, but taking the time to do so can help you.A better understanding of your health history can help you to make treatment decisions, communicate effectively with physicians, and maximize the insurance coverage that you may be eligible for.Some strategies to decipher your medical records include looking up any confusing medical jargon, focusing mainly on the conclusions rather than sifting through all of the information, and asking your doctor for clarification and further explanations when needed.
Step 1: Determine which type of record you want to look at.
Depending on the type of record you are looking for, the process of accessing your medical records will be different.You can get a copy of the vaccine record through your local public health authority or your family doctor.If they don't have it on file, you can check with your parents.You can get your dental records through your dentist.You may be able to obtain hospital records through the hospital administration or your family doctor.You can get your primary care records from your family physician.If you want to submit a formal request for your records, you can inquire with the receptionist at your doctor's office, the hospital administration staff, or the public health staff.If there is a cost to get a copy of the records, it should be low.A release of information form must be signed and submitted to the medical records department of most larger hospitals.You have the right to get copies of your healthcare records.The time frame in which you receive your records is variable and may require some waiting on your part.If you are working with a new doctor or dentist, you may be able to request a copy of your old records directly.It is worth asking your new doctor if this is the case for you.The availability of a written explanation of key points alongside your records varies on a physician-to-physician basis.
Step 2: Take a look at the various parts of the vaccine record.
There is a chance that you don't have a complete vaccination record in one place.It is advisable to keep personal records of all vaccines you have received, as well as the physician that administered them, so that official records can be tracked down more easily if and when needed.To put together your vaccine records, combine your personal records with the records you can get from healthcare facilities where you were shot.If there is a "immunization registry" in your area, you may be able to combine this information with it.The purpose of an "immunization registry" is to have all of your vaccine information in one place.You should note the date the vaccine was received, the dose, and the facility where it was administered in your records.All shots related to a specific vaccine are required to have full immunity, as some come in a series of multiple shots.The effectiveness of certain vaccines can be affected by the date.If your vaccine records are incomplete, your doctor will probably advise you to get a vaccine with any missing shots in order to be safe.
Step 3: The contents of your dental record can be found here.
The treatment, follow-up, andoutlook for any oral health issues you have had will be included in your dental record.x-rays, tests, and any other investigations you have received for your oral health will be included in your dental record.The most recent procedures will be located in the front of the file, while the ones from your past can be found at the back.If you're having trouble finding the paperwork for a dental procedure, your dentist or office receptionist may be able to help you.
Step 4: The most relevant and helpful information can be found in your medical record.
All of your medical information from birth through to the present day can be found in medical records.The oldest documentation at the back of the file will be arranged with the most recent documentation.Progress notes, lab tests, and specialist referrals are some of the sections in your medical record.To make it easier to find things.
Step 5: The medical terms should be looked up.
Understanding all of the medical terms used in the reports can be a challenge if you're trying to decipher your electronic medical records.The most efficient and effective way for physicians to communicate with one another regarding your health problems is through jargon.It provides accurate insight into the nature of the diagnosis using very few words, and it provides valuable information to the doctor looking after you; however, the challenge comes when you are trying to read the medical record yourself and find that there are terms you have never heard of before.The Internet allows you to quickly look up medical terms and get a definition of what it is referring to.This can help you understand what the doctors are talking about in your record.
Step 6: The conclusions are more important than the whole report.
Medical records contain a wide range of documents, from blood tests and other test results to medication lists, to general notes on the condition at hand, not to mention previous documentation from prior medical conditions.The progress notes, the test results, and the treatment plans are the most important documents for patients.The simplest way to read the progress notes is to focus on the conclusions rather than the information in the report.All the important information is summarized at the end in a few sentences, and the rest of the information in the report is beyond the level of detail that you will need to know.If you can decipher the few sentences in the conclusion, you will be well ahead of most patients in terms of the level at which you understand your diagnosis.The rest of the report is intended to be a back-up documentation for doctors to remember how they came to conclusions, why they made treatment decisions, or if they need to justify any medical actions or decisions with the legal system.
Step 7: Ask for clarification from your doctor.
Bring the documentation that is confusing you into your next doctor's appointment and ask him for clarification if you are having trouble decoding your medical records.This is part of your doctor's job, and he will usually be happy to answer any questions pertaining to your diagnosis, treatment plan, test results, or any other inquiries you may have regarding your current health condition.If these documents are available, you can ask your doctor to print a copy of the latest updates on your health condition while you are in the office with him.Most doctors have access to a printer.You can go over the latest paperwork with your physician by your side, who will most likely focus on the conclusions and explain the impact this will have on your treatment moving forward.
Step 8: Understand the significance of the codes for billing and insurance claims.
CPT codes are not used in other parts of the world.To determine what fraction of healthcare costs you are responsible for, as opposed to the portion that will be paid by your insurance company, the key thing to learn about and to be aware of is CPT codes.The codes are standardized so that they can be easily applied and utilized for billing purposes and insurance claims.A CPT code is a number that is circled by your healthcare provider and represents the service you received.There are roughly 7,800 codes in this system.If it isn't attached to your medical record, you should contact the person who provided you with the record to inquire about the code.
Step 9: You can make the best treatment decisions if you stay informed.
Investing the time and effort into understanding your medical records, and asking your doctor for clarification when needed, can make a huge difference in terms of your ability to effectively make decisions.For many diseases the treatment choices are fairly straightforward and do not require a lot of thought; however, for some diagnoses such as cancer, there are a plethora of options available, some of which are well-proven and others that are more experimental.It is important to have a good grasp of your condition in order to make the best decisions for yourself.Understanding your medical records is the best way to ask clarifying questions.You can fully understand the risks and benefits of various treatment options, as well as the toll they may take on your lifestyle, from this solid understanding.It is possible to determine which one best serves your needs.
Step 10: You should maximize the efficiency of the care you receive.
If you take the time to understand your medical records, you will be able to help another doctor fill in for you, which will maximize the quality of care you receive.Sometimes, when your normal physician is away, or when you suddenly develop a problem and need to go to the ER, you will be cared for by another doctor.It can make a world of difference if you are able to accurately explain your medical history and your current diagnosis, as well as describe any new symptoms or complaints.There are many times when precious time is wasted in the Emergency Room trying to figure out what is relevant and what isn't.It will help the new doctors in the moment and allow you to receive the best care possible if you can provide this information upfront and demonstrate a level of understanding about your disease.
Step 11: You can receive insurance benefits if you become aware of them.
One benefit of going through your medical records is that it increases your awareness of what is going on with your health so that you can maximize the amount of coverage you receive for the medical expenses you incur.Being informed and taking the time to review your medical records have many benefits.
Step 12: Make sure to correct any medical errors in your record.
If you find an error in your medical records, you can take it upon yourself to request that it be corrected.If you have an error corrected, it may be minor with no significant impact for you moving forward, or it could be major, resulting in improved coverage and insurance benefits.According to specific guidelines, all errors in medical records need to be corrected.The old documentation can't be erased or "obscured" in any way.The error must be crossed out in such a way that it is still legible, with a note inserted into the medical record explaining the correction and being open and upfront about how the error occurred.The medical records do not have to be changed if the patient doesn't like what the doctor says.They may note that you disagree with the diagnosis.