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Organizing Medical Files

by Heather K. Wingo
September 2023

This upcoming October is National Organize Your Medical Information Month. Don’t let this task spook you from getting the best health care you deserve. Hopefully, these tips will help you organize your information to help you and your loved ones.

Developing your system for organizing medical information or creating a Personal Health Record will help you stay on top of doctor’s visits, medications, and insurance claims. Having your medical records may help you receive safer and quicker treatment if you change doctors, move, get sick, or end up in the emergency room.

Create a Doctor Directory & Medication List

The first page of your Medical Information file should include your name, date of birth, blood type, and a table of contents for your files. Jot down all healthcare providers, their information, and their role in your care. This is important because juggling many contacts and appointments can take time and effort. Record the names, medical practices, addresses, and telephone numbers of your doctors and pharmacists. Include the emergency contact information of a caregiver, family member, or friend in case of an emergency. Include your health insurance company's name, policy number, address, and telephone number.

Example:

DOCTOR DIRECTORY
PCP (Primary Care Physician)        Doctor Name                            (XXX) XXX-XXXX
                                                                Clinic Name
                                                                Street Address
                                                                City, State Zip Code

EMERGENCY CONTACT(S)
Relationship                                       Name                                           (XXX) XXX-XXXX
                                                               Street Address
                                                               City, State Zip Code

HEALTH INSURANCE
Company Name                         Policy Number: XX-XXXXXX           (XXX) XXX-XXX
Street Address
City, State Zip Code

Include a list of current and past supplements, prescriptions, and over-the-counter medications. Write down the drug name, dosage, start date, end date, and the condition it treats, plus any side effects experienced. You may even want to include pharmacy printouts that accompany prescribed medications.

Example:

Drug Name     Dose         Frequency       Start             End                  Physician                  Condition

Tylenol              500 mg     once a day       01/01/20       01/02/20          Over the Counter     Fever

Notes
Helped to break my fever quickly.

Organize Medical History

Keep these Records on hand and organize medical history and current health information categorically and chronologically. Everyone has a different health history. Therefore, how you categorize your records is a personal decision. Essential records more than a year old may be packed away, but keep documents from the past year readily accessible. Below is a list of documents that you may want to file. You will find the outline is categorized in a way that you may want to use to organize your files. 

Medical History

• Personal Health History
  • Information that may be need in an emergency, e.g. a pacemaker, stent, or hearing and vision problems.
  • A list of long-term/chronic health problesm, e.g. arthritis, asthma, diabetes, or high blood pressure.
  • A list of allergies, including drug or food allergies. 
  • Immunization Records
• Family Health History

Medical Records

• Doctor visit summaries and notes (dates, doctor names, and notes)
• Hearing, vision, and dental records
• Hospital discharge summaries
• Test results (dates and results of test and procedures)
• Health Screenings (cancer screenings e.g, Pap tests, mammograms, colonoscopy, and PSA tests)

Billing

• Insurance Forms and Billing
  • In chronological order, organize copies of all bills and receipts from doctors' offices and any insurance payment documentation like explanation of benefits forms. Keep records of insurance claims, payments, and balance information. 
• Legal Documents (e.g., living will, power of attorney for health care)

Log Symptoms and Side Effects

If you or a loved one have a chronic condition, log relevant factors like blood pressure and blood sugar. Include the time of day so your doctor can help determine whether changes in your health measurements are related to the condition or medications. Note any changes in nutrition, activity, and stress levels.

Also, log how you or your loved one responded to medications and treatments. Be specific with the name of the drug, the dose, and what happened. This record will come in handy when determining the adverse effects of treatments down the line.

Keep Copies and Take Advantage of Technology

Whether you use technology or paper files, be sure to have a backup of your information. You may also want to keep a copy of your records with a loved one. Consider using a three-ring binder or file folders to transport, store, and update your medical records.

Different healthcare providers may offer online records you can access. If you want an app to manage your health records – ask your primary care doctor for recommendations. If you use online tools, share your login information with a backup contact, make duplicate electronic copies of scanned or photographed documents, and save them on your computer to mirror the organization of your paper files.

Resources:

Arbaje, A. (2023). Medical records: Getting organized. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/wellness-and-prevention/medical-records-getting-organized

Medicare.org (2023). How to organize your medical information in 5 easy steps. https://www.medicare.org/articles/how-to-organize-your-medical-information-in-5-easy-steps/