Reviewing the medical record is a critical part of being a consciousness, careful and successful doctor. For fertility specialists, this means reviewing lab tests and prior treatments (like IVF), as well as appraising the general medical history. By reviewing records we can avoid repeating unnecessary tests, more quickly focus on important issues and more successfully design a treatment plan. This blog will focus on obtaining, organizing and using the medical record for fertility care.
The medical record is an ever-changing collection of objective medical results such as lab tests and pathology findings as well as subjective impressions like doctor’s notes and operative reports. Together, these documents illustrate a person’s medical history with accuracy and detail.
Many people are intimidated by their medical record. The record can contain hundreds of pages with confusing numbers, scary words and images, not to mention illegible doctor handwriting! Importantly, with just a few easy steps, the record can be organized and refined into a manageable and useful tool.
Step 1. Request your records;
It is important for everyone to know that their medical record is their own personal property. Although a doctor may store your record at her or his office, the record is technically yours. Thus, a patient should never be hesitant to ask for copy of their record. Most offices have a simple form for the patient to fill out and once completed, they will provide you with a copy of your record within 72 hours. Some offices may charge a nominal fee for this service, but they can never deny your request.
Importantly, to get a complete picture, you may have to request records from all of your doctors. This might require several separate requests, and while this can make things confusing, it is worth the time.
Step 2. Organize the records;
I find that the easiest way to organize records is chronologically. Everything that happens in a doctor’s office will have a date attached. Because records are usually stored in separate parts of the chart, they usually do not come to you in a chronological order. You should simply look at each piece of paper and order them from oldest (in the front) to newest (in the back). This order allows the records to be reviewed like a story. If there are multiple records from the same day, try to put the doctor’s notes first, then the lab results second.
At this point it is usually a good idea to make a copy of the records for yourself. Doctors are notorious for losing records. By having your own copy, you won’t be forced to go through the above steps more than once.
Step 3. Summarize the records;
This part can be a little difficult for a non-medical professional, but I usually take a piece of paper and write the date on the left side then a single to a couple lines summarizing the findings for that day. Eventually, you build a one to two page summary with dates and findings in an easily referenced format.
Knowing and using your medical record is important for all patients. Whether reviewing IVF cycles, assessing recurrent pregnancy losses or understanding prior surgeries, a well organized and summarized record will help streamline your care in the future.
If you have questions about your medical record or would like to discuss treatment plans with us, don’t hesitate to contact us, we are happy to speak with you.