Although physicians and other health providers are required to keep medical records, families should keep their own health records also.
A health record should include medical history (conditions and diagnoses), doctor visits and hospitalizations, immunization record, surgeries, other procedures, medications, allergies and ongoing therapies. It may also include recent test results and a listing of any medical or assistive devices used.
There are many forms available for keeping track of health information. Some can be completed and saved online. Others need to be printed out. Here are some samples:
- Health Care Notebook (Parent to Parent): Extensive, not fillable online.
- Building Your Care Notebook (National Center for Medical Home Implementation): Can choose from variety of forms to individualize the care book; fillable but not able to be saved online.
- Keeping a Health Summary (Healthy Transitions NY): Provides a description of why a health record is important and steps to create one.
- Transition Information Form (Healthy Transitions NY): Fillable and able to be saved online.
- Health Information Form (WIHD): Fillable and able to be saved online.
- Keeping a Health Summary Video (Healthy Transitions NY): Shows a parent explaining why it is so important to keep health records.
In addition to keeping a complete health care record, it is important to have a short health summary to carry for emergency situations. It should include information on health conditions, medications, allergies, immunizations, doctor and pharmacy, and insurance. Also include safety concerns and special medical or behavioral needs. This should be no longer than two pages. Keep it in a wallet or backpack. You can also keep it on a flashdrive on your keychain or on a smart phone.
Here are some samples of short forms that can be used:
- My Health Summary (WIHD): Fillable and able to be saved online.
- Emergency Information Form for Children with Special Needs (AAP, ACEP): Not fillable online.
- H.I. Doc (NYS DOH): Not fillable online; print or call 518-474-2001 for pocket versions.
Some health care offices allow you to access medical records online. Check with your family member’s physicians to see if this is available, and whether the electronic health record can be accessed by other health providers. You may want to store your health information on your own devices. For general information on tools to help you manage your personal health records go to:
- Maintain Your Medical Record (Health IT.gov)
Examples of applications for smart phones and tablets include:
- My Medical: Provides organized data base for medical information; can store documents like x-rays; connects with calendar to store appointments; can track test results; stored only on your device, not internet; can secure with password; available for Apple and Android devices.
- Track My Medical Records: Stores health information; quick recall emergency contact information; information backed-up on secure internet site; only for Android devices.
- Capzule: Stores health information; pill reminders; PDF summary reports available; only for Apple devices; can copy between devices.
However you do it, carry health information with you and keep it updated.