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Health Care Reform:

Health Insurance & Affordable Care Act

Organizing Your Medical Records - Topic Overview

Use your computer

Use any software program you're comfortable with, or get software specifically for personal medical records.

Another option is to store your health records on a secure Internet site. Your health plan or hospital may have one that you can use for free.

The American Health Information Management Association (AHIMA) sponsors an Internet site where you can search for paper-based, software-based, and Internet-based personal health record systems. Go to www.myphr.com.

What records should you have?

Your medical records should include:

  • Current health information.
  • Your medical history.
  • Records of recent insurance claims and payments. Experts advise keeping these for up to 5 years after the service date. But if they're related to your tax returns, keep them for 7 years, along with those tax returns.
  • A copy of your advance directive, including a living will and power of attorney.

Current health information

Current health information includes:

  • Information that is needed in an emergency, such as whether you have a pacemaker or a stent or have hearing or vision problems.
  • A list of your long-term (chronic) health problems, such as arthritis, asthma, diabetes, or high blood pressure.
  • A list of the medicines you are taking. Include prescription and over-the-counter medicines, dietary and herbal supplements, and vitamins and minerals. For each medicine, give the name of the doctor who prescribed it, why you are taking it, how much you take, and any special instructions.
  • A list of your allergies, including drug or food allergies.

Your medical history

Keep records of:

  • Major health problems you've had in the past, such as pneumonia or broken bones, or problems with alcohol or drugs.
  • A history of childbirth, if you're a woman. This includes how many children you've had and any miscarriages, cesarean sections, or abortions you've had.
  • Your childhood and adulthood immunizations.
  • Any health screening results, such as those for blood pressure, cholesterol, vision, and hearing.
  • Any cancer screenings, such as Pap tests, mammograms, colonoscopy, and PSA (prostate-specific antigen) tests.
  • Any surgeries or times you were in the hospital.
  • Your hearing and vision checkups.
  • Medicines you've used in the past.

WebMD Medical Reference from Healthwise

Organizing Your Medical Records Topics

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