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What is a Personal Health Record (PHR)?

The PHR is a tool that you can use to collect, track and share past and current information about your health or the health of someone in your care. Sometimes this information can save you the money and inconvenience of repeating routine medical tests. Even when routine procedures do need to be repeated, your PHR can give medical care providers more insight into your personal health story.

Remember, you are ultimately responsible for making decisions about your health. A PHR can help you accomplish that.

Important points to know about a Personal Health Record:

  • You should always have access to your complete health information.
  • Information in your PHR should be accurate, reliable, and complete.
  • You should have control over how your health information is accessed, used, and disclosed.
  • A PHR may be separate from and does not normally replace the legal medical record of any provider.

Medical records and your personal health record (PHR) are not the same thing. Medical records contain information about your health compiled and maintained by each of your healthcare providers. A PHR is information about your health compiled and maintained by you. The difference is in how you use your PHR to improve the quality of your healthcare.

Take an active role in monitoring your health and healthcare by creating your own PHR. PHRs are an inevitable and critical step in the evolution of health information management (HIM). The book “The Personal Health Record” assists new users of PHRs in getting started, addressing current PHR trends and processes.

The specific content of your health record depends on the type of healthcare you have received. Listed below are documents common to most health records and additional documents that accompany hospital stays or surgery.

Reports Common to Most Health Records:

  • Identification Sheet – A form originated at the time of registration or admission. This form lists your name, address, telephone number, insurance, and policy number.
  • Problem List – A list of significant illnesses and operations.
  • Medication Record – A list of medicines prescribed or given to you.
  • History and Physical – A document that describes any major illnesses and surgeries you have had, any significant family history of disease, your health habits, and current medications. It also states what the physician found when he or she examined you.
  • Progress Notes – Notes made by the doctors, nurses, therapists, and social workers caring for you that reflect your response to treatment, their observations and plans for continued treatment.
  • Consultation – An opinion about your condition made by a physician other than your primary care physician. Sometimes a consultation is performed because your physician would like the advice and counsel of another physician.
  • Physician’s Orders – Your physician’s directions to other members of the healthcare team regarding your medications, tests, diets, and treatments.
  • Imaging and X-ray Reports – Describe the findings of x-rays, mammograms, ultrasounds, and scans. The actual films are maintained in the radiology or imaging departments or on a computer.
  • Lab Reports – Describe the results of tests conducted on body fluids. Common examples include a throat culture, urinalysis, cholesterol level, and complete blood count (CBC). Surprisingly, your health record does not usually contain your blood type. Blood typing is not part of routine lab work.
  • Immunization Record – A form documenting immunizations given for disease such as polio, measles, mumps, rubella, and the flu. Parents should maintain a copy of their children’s immunization records with other important papers.
  • Consent and Authorization Forms – Copies of consents for admission, treatment, surgery, and release of information.

Additional Reports Common to Hospital Stays or Surgery:

  • Operative Report – A document that describes surgery performed and gives the names of surgeons and assistants.
  • Pathology Report – Describes tissue removed during an operation and the diagnosis based on examination of that tissue.
  • Discharge Summary – A concise summary of a hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet, and follow-up care.

Your records may contain some or all of the documents above. Depending upon your illness or injury, you may use the services of the emergency room, intensive care unit, a physical therapist, or home health nurse. Often these specialized services have unique evaluation, measurement, and progress reports wich you may also find in your health record.

The information in your medical record is used to monitor your health, coordinate the care you receive, and ensure that quality healthcare is being delivered—but that’s just the beginning. It also travels to many different places both inside and outside the healthcare system. Your information may be used for research, as a legal document in cases where evidence of care is needed, and to pay for the care you receive.

By healthcare providers:

Most healthcare organizations have quality assurance departments. People in these departments review patient information in order to monitor and improve the quality of care you receive. Your information may also be used for research and as a legal document in cases where evidence of care is needed. For the most part, anyone who wants to use it for any other purpose needs your permission first.

Hospitals can share information with family members without your authorization if you are unable to consent and a family member (such as spouse, parent, or child) is involved in providing your care. For example, your spouse or child may be involved in caring for you following a hospital stay (by helping you in and out of bed, to bathe, changing bandages, and similar activities). You can simplify things at the time you are admitted to the hospital (or nursing home) by specifying which family member you want to receive information about you.

By insurance companies:

After your health information is collected, it is used to bill for the services you received.

Your patient data for billing purposes is usually transmitted electronically to those paying your bills, such as your insurance company, although the company may request paper documents in support of the bill. Your information is often identified by your name, patient identification number, address, phone number, and social security number.

Your health insurance company receives your health information through the claims provided by the patient accounts/billing department at your healthcare facility. The coded data is then evaluated automatically to identify appropriate payment for the services you received. Your insurance company may ask your provider for more information to validate payment if the claims submitted were not complete enough to support what was being billed.

 You can play a more active role in your healthcare. Research has shown that when consumers actively participate in their own care, the outcomes are better. Use your PHR to assist with decision-making when it comes to potential health conditions, treatment options, costs of treatment, management of chronic conditions, healthy lifestyle choices, preventive actions, and monitoring the accuracy and security of your health information.
Did you know that every time you see a doctor, visit a hospital, clinic or health care facility a record of your personal health information is kept?

Your blood type, allergies, vaccinations, past procedures, all information that can help medical professionals give you fast, efficient treatment if it’s kept in one convenient place. This information is compiled into what is known as your medical or health record and is protected under the Health Insurance Portability and Accountability Act, also known as HIPAA.

It is important to understand that PHRs – which generally are not part of a provider’s electronic health record – are not considered legal health records and therefore, are not covered by HIPAA.

Chances are, you have a lot of different medical records. You may see many different healthcare providers during your lifetime such as a family practitioner, an allergist, a specialist such as a cardiologist, and if necessary, a surgeon. Each of these providers compiles a separate file of information about you. In fact, even if your providers are all part of the same health care system, they may each keep a separate medical record for you and may not be aware of the other treatment you are receiving. This can lead to an incomplete and disconnected record of your health. This is why your PHR and how you use it is important. Our experts discuss the benefits and risks involved in selecting the appropriate PHR.