Medical records kept for patients by doctors are considered the property of the patient. Changes can be requested if errors are found, and copies must be given to the patient. Parents have access to their children's medical record while the children are still minors. Also, persons with legal guardianship or power of attorney have access to the medical records of persons in their care. In some instances, authorities have access to medical records also. There are privacy laws governing who has access to a person's medical record, what information records contain, and how such records are to be handled or disposed of when one dies. These laws often differ from state to state regarding medical records. Most medical offices still have the paper files of medical records on hand but are in the process of converting it all to computer files that can be more easily shared between patient, health care providers, and other medical establishments.
The medical record of a patient should contain:
- Family health history
- Medications and supplements taken
- Social information on the patient (relationship, emergency contacts, employment, community involvement, etc)
- A chronological listing of illnesses or diseases that the patient was seen and treated for
- Growth landmarks
- Surgical records
- Obstetrical history for females
The category of disease or illness treatment is expanded on greatly because for each office visit, the physician should have put together SOAP notes for the record that included documentation of the symptoms, vital signs, diagnosis, tests ordered, outcomes of any tests, options for treatment, risks and benefits of evaluations,tests, treatments, or the option of not treating. Patient consent for treatment is a helpful document for a doctor to have as part of the medical record. Care plan and care provided, care outcome should all be included in a medical record for each instance of illness. Some other information one might find in a medical record would be recommended referral, additional information of conditions the doctor might have researched (including articles, helpful organizations, pictures, charts, diagrams, etc), any injury reports from employers if patient was seen for a work-related injury, policies or protocols of practice, billing and insurance information.
If a person refuses treatment, the doctor will often require a signature confirming that the patient understands the implications and possible complications that can result from not being treated. It is every person's right to refuse treatment, seek second opinions, or do nothing at all. This might not apply, however, to parents refusing treatment for a child or someone under their guardianship (see more in article on informed consent). Every person has the right to decide what happens to their body. Most doctors' medical opinions can be seen as good advice, but should not be thought of as absolute. One's own judgement and knowledge of their own body are factors that are also worthy and important in the overall decision-making process when it comes to one's health.
Doctors are professionals that most look up to for their knowledge and experience but they are human and make mistakes like everyone else. Make sure you review your medical records from time to time. If errors are found, request that they be corrected. If you change doctors or are referred to additional care providers, make sure up-to-date copies of your medical records are sent to them. Additionally, ask your doctor any questions or state any concerns that you have regarding your body or your health. They should answer in terms and language that is understandable. This is part of informed consent. If you have a doctor that makes you feel like they do not have time for you, or makes you feel uncomfortable asking questions, then you should seek another care provider.