What Is a Medical Record?
Article Translations: (Spanish)
A medical record is a history of someone’s health. Most hospitals and doctor’s offices use electronic health records (EHRs, also called electronic medical records or EMRs). An EHR is a computerized collection of a patient's health records.
What’s in a Medical Record?
A medical record includes information about a person’s:
- age, gender, and ethnicity
- height and weight
- medical problems (such as asthma, epilepsy, or diabetes)
- mental health issues (such as anxiety or depression)
- medical test results (from lab tests, X-rays, etc.)
- medicines, including doses and how often the medicine is taken
- allergies to medicines (both prescription and nonprescription), insect stings and bites, food, and any other substances (such as latex)
- surgeries and hospitalizations
- immunizations (shots)
- billing and insurance
Who Can See My Child’s Medical Records?
Usually, doctors can share medical records for kids under 18 years old only if the patient’s parent or legal guardian gives permission. In some situations, though, doctors can share them without that permission (for example, if the child’s health or safety is at risk).
The rules about privacy of medical records are based on a federal law called the Health Insurance Portability and Accountability Act (HIPAA).
Are All Electronic Medical Record Systems Connected?
If you say it’s OK, your child’s EMR usually can be seen by all doctors and departments within the same health care system. For example, if your child’s pediatrician and dermatologist both work at the same hospital, they could share records electronically. But if your child goes to a doctor who works at a different hospital, you may need to ask for those records to be shared.
How Can I Get Copies of My Child’s Medical Records?
Parents whose kids are under 18 years old can get copies of most of their child’s medical records. You’ll fill out an authorization form so your doctor knows what information you need. You may want the entire record (for example, if you are changing doctors) or only specific information (such as reports from a surgery or test).
Depending on which state they live in, parents no longer have access to a child's mental health records (like the notes a therapist takes during counseling sessions) when their child is 15 or 16.
What Else Should I Know?
You may want to keep an electronic or paper copy of your child’s medical record. This will make it easier to share medical information when needed (for example, with a medical specialist or new doctor, or if your child goes to the emergency room). It also can make it easier to fill out school, camp, and childcare forms.
Note: All information is for educational purposes only. For specific medical advice, diagnoses, and treatment, consult your doctor.
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