The @&## With Doctor's Orders

Now that my proficiency of using my left hand for the mouse has improved and I can type with my left hand (all be it slowly), I will be back to posting as I am able to complete a blog. Thank you readers for your patience!

No, my wrist is not healing, and the doctors cannot figure out why.

Doctor Ordered Vacation

Had not wanted this, but to heal my injury more rapidly, I will be following doctors orders until I feel I can use my right hand again.   Tendonitis is the problem.  Hope it heals fast.

What You Don't Know Can Hurt – Even Kill You

“Is it possible for a health care system to redesign its services to better educate patients to deal with their immediate health issues and also become more savvy consumers of medicine in the long run?” This is an important question and even larger dilemma for the medical profession to solve. I would also state that the patients need to pay attention as this poses a question for patients - “How do patients make good choices?”

Two different articles from different perspectives are very interrelated and important for both sides in the near future. Even being aware of one side before I wrote this blog on the August 23, the blog posted by Nancy Finn on September 3 really brought the topics together for me. Both the medical profession and the patients have a challenge before them and solutions are not easy to come by. This also brings another question into play - “Can both sides work together to solve this?”

I will say that for many, this will be possible on both sides, but I wonder how we will bring those on both sides that will oppose this very rigorously into the desired state of learning. Many physicians are of the opinion that patients should listen only to them, the doctors, and follow their directions explicitly. On the patient side, there are many that will have no desire to learn and will insist on following the doctor without learning anything about the reasons or the medicine behind the condition.

The importance of health literacy is more important today than in the past for several reasons. People that are literate become more adept at understanding health information, tend to make more informed healthcare choices, become better able to manage their chronic conditions, and in general have significantly better outcomes than patients that remain health illiterate. Patients that remain healthcare illiterate have higher rates of medication errors, more emergency room visits, hospitalizations, and increased likelihood of dying.

A number of health policy organizations recognize that health literacy is important to individuals, and benefits society because helping patients help themselves is an important pathway to keeping down health care costs. Successful self-management reduces disease complications and can cut down on unnecessary emergency room visits and eliminate other wasteful spending.

Organizations that promote proper health literacy tend to do certain things very well. The ten (only nine are listed) attributes in the report include items such as:

1. Making improving health literacy a priority at every level of the organization;

2. Measuring health literacy and using those measurements to guide their practices;

3. Taking into account the particular needs of the populations they serve;

4. Avoiding stigmatizing people who lack health literacy;

5. Providing easy access to health information and assistance navigating services;

6. Distributing easy-to-understand information across print, audiovisual, and social media channels;

7. Taking health literacy into account when discussing medicines or in other high-risk situations by using proven educational techniques, such as the teach-back method;

8. Training the healthcare workforce in health communication techniques; and

9. Letting patients know what their insurance policies cover and what they are themselves responsible for paying.

When you consider what is on the plate for patients, the medical decisions have changed from leaving the choice of treatment entirely in the hands of your doctor to the patient now needing to be informed and choose between treatment choices. These decisions are often life altering, and it is now up you or your families to choose which way to treat your medical issues. This change has occurred because for many conditions:

(1) There are no clear-cut parameters with proven success;

(2) The medical experts differ regarding the best way; and

(3) Although there is an abundance of information about medical issues, that information is often difficult to comprehend.

Nancy Finn accurately explains many of the decisions we as patients may need to make and the task does look daunting to say the least. What may seem simplistic on the surface, can be very complicated when it is your life on the line. Healthcare literacy is important and if you have great doctors that are willing to take the time to educate you, the decisions will be difficult, but you will have a solid base on which to make the decision.

This is why becoming an e-patient may be a goal you need to set for yourself. Even then with all the diseases and types of illnesses, this is a formidable task. This is just one more reason that e-patients form groups that can mentor others.

Will New Tool Really Help Dietitians?

When I read this, I could not believe that this was being said by a registered dietitian. I mean that she is right in what she says, but to say it publicly has to be daring. It is so important that I am going to quote it, "Only 80 percent of the dietitians we surveyed did any pre-assessment of the client's nutrition literacy, which makes it difficult for educators to target their counseling so clients can understand and act on the information they are given." Karen Chapman-Novakofski is a registered dietitian (RD) and University of Illinois professor of nutrition extension.

From a profession that lives by its mandates, mantras, and dogma, this RD speaks very plainly about why dietitians and some nutritionists are often ignored by their clients. The attitude of RDs is so ingrained in their mantras that they do not pre-assess what their patient (client) has knowledge of and what they need to be taught to make the information useful.

I know that I am not surprised at her findings in the survey. Here we get into using terms that are not explained as well as they should be. Before today, I would have thought a nutrition educator was a teaching position at a college or university. On doing my research, this is true, but also encompasses nutrition educators in hospitals and medical centers as well. Some are also involved in business nutrition education, like agriculture businesses Archer Daniel Midlands, Monsanto, and the food industry.

If the 80 percent is from academia, and the medical arena, then this is why we get the mandates, mantras, and dogma. However, I do think that the term nutrition educators is just the latest phase we are going to have to get used to coming out of the Academy of Nutrition and Dietetics. A doctoral student, Heather Gibbs, has developed an algorithm that dietitians can use to determine precisely what knowledge and skills are required for a particular client.

I know algorithms can be very powerful tools, but I wonder how this will help a profession that works with mandates, mantras, and dogma. They seldom change and will avoid the algorithm as they are not as interested in education as they would lead you to believe. It could be that this may be about to change, but I would not get too enthused yet.

Some patients or clients as they are termed in this article need to know how to manage their consumption of carbohydrates, protein, and fat. Many more need to learn how to manage portion sizes and others need to learn how to read labels. Then many clients need to be able to categorize foods into nutrition groups properly. So with this algorithm dietitians will have the questions to assist them in assessing what the knowledge is that the client possesses and then teach the client what they need to know be become more nutritionally knowledgeable and manage their nutritional needs plus work to balance their daily nutrition.

Karen Chapman-Novakofski stresses that until health professional start asking questions to see what knowledge the patient has about nutrition, it will be impossible to effectively teach nutrition and create a behavior change. She also stated that until dietitians narrow their focus and understand what skills and literacy the client patient possesses, they cannot deliver information in a way that will be meaningful or usable by the client.

Dietitians must get away from the education level of the patient to understand that the patient and the level of nutrition they possess. Then the dietitians can adapt the education to fill in the gaps and make the information usable for the client. Chapman-Novakofski also said if you're the one being counseled, don't be afraid to ask “how” questions to force the dietitian to keep the discussion on your level.

The area Chapman-Novakofski did not cover was how to get the dietitian away from mandates, mantras, and dogma. Until these three areas are made useless to the dietitians, little nutritional education will be passed in a usable form for the clients.

Patients Not Seeing Progress in Meaningful-Use

The Centers for Medicare and Medicaid Services (CMS) on August 23, 2012  released the final version of its second-generation criteria for "meaningful use" of electronic health records (EHRs). This will supposedly make it easier for physicians to earn bonuses and avoid penalties; however, little in the final version will benefit patients and their ability to view online their medical records. Again, the resistance of the American Medical Association has reared it ugly head to continue to make it difficult for patients to have transparency of their EHRs.

Two areas where physicians were able to delay aggressive implementation are the electronic transmission of prescriptions and delay of ability of patients to have access to their EHRs. Neither of these should have been that difficult to accomplish, but the AMA in their infinite wisdom have lobbied for slowing the progression of e-prescribing and wanted to junk the provision for patient online access.

On the topic of electronic prescribing, Stage 1 required physicians to transmit more than 40 percent of their scripts to the pharmacy. CMS in the proposed rules wanted to increase the threshold to 65 percent. The AMA and other medical groups held out for 50 percent and the CMS settled on 50 percent in the final regulations.

I am not surprised that the AMA and organized medicine is so opposed to letting patients view their health data online – they have something to hide. They wanted this entire part of Stage 2 thrown out. CMS had proposed a rule allowing more that 10 percent of patients to have access to their EHRs starting with Stage 2. Organized medicine says that CMS should not hold physicians accountable for patient behavior beyond their control. Thank you CMS for keeping this provision as part of Stage 2, but you should not have lowered it to 5 percent.

CMS did regrettably give four exceptions to meaningful use penalties to Stage 2 in 2015 for not achieving meaningful use and they are:

1. Infrastructure: Clinicians must prove that they practice in an area with inadequate Internet access or "insurmountable barriers" to obtaining it.

2. New practitioners: Clinicians who begin practicing in 2015 would be exempt from the meaningful-use penalty in 2015 and 2016, but they would have to demonstrate meaningful use in 2016 to avoid the penalty in 2017.

3. Unforeseen circumstances: Physicians may be able to avoid a penalty if natural disaster or some other unforeseeable event prevented them from meeting EHR meaningful-use criteria. CMS will consider this exception on a case-by-case basis, and sparingly so.

4. Scope of practice: Medicare will refrain from penalizing physicians who cannot achieve meaningful use by virtue of how they practice. They may not routinely see patients face to face, for example, or they may practice in multiple locations where they have no control over the availability of EHR technology.

However, CMS is not afraid to tread in areas they maybe should not have. CMS did deny a proposed exception for physicians nearing retirement. AMA and its cohorts wanted to exempt physicians if they are currently eligible or would be eligible by 2014 for Social Security benefits. CMS simply stated that a practitioner's age does not constitute a significant hardship.

Diabetes Self-management Education – Part 2

In part 1 of this blog, I discussed much of the importance of diabetes self-management education (DSME) and mentioned diabetes self-management training (DSMT) in mainly the context of use by certified diabetes educators. The article from this link provides much information. There are a few more points to be discussed and emphasized before I discuss more about peer mentors and peer-to-peer workers using this (DSME) to supplement self-monitoring of blood glucose (SMBG).

The topics of depression, physical disability, personal preferences, and quality of life were mentioned and need more emphasis. It is also important to consider hypoglycemia, life expectancy, and the incorporation of other professionals in the care of the elderly. These topics are important for professionals and need to be learned by peer mentors and peer-to-peer workers.

Mild depression for people with type 2 diabetes is about two-thirds of them and less than one-fifth may have severe depression. The article states that the rate of depression in patients is at least two times higher than the general population. It then continues to say the risk of an older person with diabetes experiencing a major depressive episode is 1.6 times higher. I think they mean the general population, but this is not said. The key of why this is important is this statement “Functional disability (difficulties performing activities of daily living and social activities) is significantly increased in the presence of both diabetes and depression, and it negatively affects self-care.” Therefore, screening for depression in the elder population is necessary. If depression if suspected, the depression needs to be resolved before any changes are made to the diabetes self-management plan.

In the previous blog, recent illness or an operation were mentioned, but physical disabilities also needs to be evaluated. The people over the age of 60 may have other physical limitations in performing the activities of daily living (eating, dressing, and toileting). They may also have problems in other areas of daily living such as using the telephone, preparing meals, traveling, and managing finances. Additionally, older adults are at higher risk of hearing loss, vision problems, decreased mobility, falls, fear of falls, and chronic pain.

Patients who are experiencing difficulties with daily tasks will need mandatory individual rather than group DSME. Treatment regimens will need to be relatively simple rather than normal or complex regimens. Learning new skills will take longer and may require referral to a visiting nurse to make sure the task is fully integrated into the patient's self-care regimen. A check back program to evaluate the learning progress may be necessary as well. A physical therapy or local elder services referral may be needed to assess the home environment and prevent potential injury from falls or accidents.

In elderly patients with type 2 diabetes, it is very important to find out what the personal preferences are with respect to care. It is well known that when patients' preferences can be incorporated into care plans, adherence increases, patient satisfaction increases, and the likelihood of improved patient outcomes goes up. Some patients will not need adjustments to their treatment plan, but others with physical or cognitive challenges, may need many adaptive changes.

For the elder type 2 diabetes patients, concern for hypoglycemia is a must if they are on insulin or a combination of oral medications and sulfonylurea is among the combinations. The elderly are more likely to be vulnerable with hypoglycemia occurring at lower blood glucose levels, be harder to recognize, and have poorer outcomes. In the elderly, hypoglycemia may show up in terms of neuroglycopenic symptoms like dizziness, weakness, confusion, and even delirium. This is unlike the symptoms of the younger generations called adrenergic such as tachycardia, palpitation, and sweating. In the elderly, hypoglycemia may aggravate common diseases such as coronary artery disease and cerebrovascular disease. The frail elderly may have outcomes such as injurious falls, even with mild hypoglycemia.

Taking the two diseases mentioned in the last paragraph and adding the two other pathological conditions of hypertension and dyslipidemia to the list and these often dominate the overall health of older patients. Functional status of older people with type 2 diabetes and cognitive decline changes the focus of care treatments from optimizing goals for diabetes to optimizing function and quality of life. The best treatment goals then become achieving the best possible glycemic management allowable, while maintaining independence and optimizing quality of life.

Factoring in that for some elderly with type 2 diabetes, life expectancy may be shorter than the time needed to obtain benefits from an intervention. Before recommending or implementing complicated, costly, or uncomfortable treatment regimens that may result in harmful side effects, it is necessary to realize that there will be reduced adherence to recommended therapies, and reduced general well-being. In other words, the time frame needed to realize benefits should be carefully considered relative to life expectancy.

Two other areas for discussion must include the use of multiple disciplines and care partners in the treatment of the elderly diabetes population. Because older patients with diabetes are clinically and functionally even more diverse than their younger counterparts, therefore they have even greater need for the services of specialists, including nurses, dietitians, exercise physiologists, behavioral medicine specialists, social workers, pharmacists, and rehabilitation professionals.

In chronic diseases such as diabetes, day-to-day care responsibilities fall mostly on patients. However, when patients are unable to assume full responsibility for their self-care, family members, friends, or other care partners may need to be involved. In older adults in particular, care partners can play a critical role in managing chronic illness, tipping the balance toward effective rather than failed self-care. If needed, family members or other caregivers should be included in DSME.

Because of the shortage of certified diabetes educators and even the absence of in many rural areas, this is an opportunity for peer mentors, and peer-to-peer workers to fill a need. For the ages about 60, the educators seem to vacate their responsibility and this creates a vacuum that needs filling. This is a reason to become educated in this area and work with the professionals that do care about the health status of the elderly. They, in my limited experience, are willing to share knowledge and give some training.

It is necessary for us to learn what we are able from these caring professional and undertake with their guidance the task of using DSME to assist the elderly diabetes patients. Communication is a must especially back to the doctor by the peer mentor and peer-to-peer worker. Because of HIPAA rules, unless a patient specifically asks the doctor to alert us of his/her medical health conditions, our participation will be severely limited.

Limitations aside, there are some elderly patients being served by peer mentors and peer-to-peer workers and the patients are sometimes filling in the information needed.  Never let the lack of information completely stop you as a peer mentor or peer-to-peer worker as the need for us is there and by learning about DSME and SMBG and other care areas, we will be useful.

Build a network of specialists, including nurses, dietitians or nutritionists, exercise physiologists, behavioral medicine specialists, social workers, pharmacists, and rehabilitation professionals, so that if the patient you are working with is in need of their services, you are able to recommend to the doctor, people that are available in that community. The doctor is the only one able to make the determination call and make the referral after evaluating your report and talking to the patient or their caregiver.

Always make a report to the doctor each time you visit a patient you are assigned and make the report as detailed as possible. What you leave out, may make a difference, so include any item even if you prioritize the list. This blog and the previous blog lists many of the areas of concern; however, it is not all-inclusive.

Diabetes Self-management Education – Part 1

Diabetes self-management education (DSME) can easily be used in place of self-monitoring of blood glucose (SMBG) to confuse the unknowing public. They both involve education of the patient in management of blood glucose; however, DSME is then taken a few steps further to expand the issue. Both are equally valuable and can be used together. Many of us stop when talking about SMBG at the end of managing blood glucose.

This is where we make the mistake and do not carry the topic as far as DSME does. DSME continues on to include the whole process of diabetes management and takes into consideration the entire patient. For that reason, there has been some separation legitimately in the titles. Sometimes certain groups use the term DSMT (diabetes self-management training). It is a shame that the group that developed this only uses it in writing and self-promotion. This group seldom uses DSME or DSMT in actual practice.

This article is about older adults, but should apply across all ages with modifications. Older patients (age 60 and older) with diabetes do account for more than one-fifth of all patients with diabetes. One statement made in the study that I may repeat is this, and I quote, “Medical care in the absence of adequate self-care is rarely effective for chronic illnesses.” This is an important point and worth emphasizing repeatedly.

DSME is the supposed goal of certified diabetes educators. If they would follow and use it, we could all benefit. Instead, they muddy it up with mantras and do not educate many type 2 diabetes patients. This is their weakness and the importance of DSME should not be diminished. DSME was originally designed for all types of diabetes – again the one-size-fits-all; however, I will be talking about type 2 diabetes for the older generation in this blog and maybe for the younger generations in a future blog.

DSME for those age 60 and older requires, and I mean requires that it be on an individual basis. There is no place for a one-size-fits-all application for the elderly. Where possible it should involve care partners when patients are not able to assume full responsibility for their own self-care. DSME should also consider the potential effects of diabetes treatments on quality of life, but at the same time, encourage all individuals who want to achieve successful health-related care.

Studies of self-management interventions clearly indicate that health behaviors, health status, and health care utilization improve with patient education in diabetes daily care. If only Medicare would stop taking away testing supplies, it might improve even more. One study compared patients that had received some diabetes self-management education with patients not receiving any DSME. Those not receiving any DSME had a fourfold increased risk for major diabetes complications. This alone points out the importance of diabetes education, and the more education the better. This also explains the importance of follow up reinforcement of what they have learned, and asking how they are doing with what they have learned. Be specific and do not accept brush-offs of the questions.

Now the one fault of DSME for the over 60 age group is they are very under-represented in DSME research studies. Therefore, what we have is a set of expert consensus formulated guidelines developed by the American Association of Diabetes Educators (AADE) and the American Geriatric Society. This also highlights the need for other groups that can step forward and fill the need for those with type 2 diabetes. Since the AADE is obviously ignoring the needs of the elderly, this opens opportunities for peer mentors, and peer-to-peer people. With the increasing number of people with type 2 diabetes, and the lack of growth in the AADE, these people will assume roles that are even more important in the near future.

First, we have discussed making sure that the diabetes self-management education is created for the individual and not a one-size-fits-all situation. This should consider how long the individual has had type 2 diabetes. Next, a determination needs to be made of existence of any complications, other medical conditions, and life expectancy. Lastly, is the individual limited in English proficiency, frail, or cognitively impaired as these must be part of the education process and made part of the care partner concerns.

Older adults should be carefully evaluated do determine their knowledge of diabetes and their ability to learn and apply new self-care skills. Social support, transportation availability, financial problems, and functional status must be assessed. Treatment goals and management skills may need to be evaluated frequently to keep pace with changes in functional and cognitive abilities, which can occur relatively quickly.

For the elder generations, nutrition is important. Be sure that the proper nutrition authority is in attendance as problems with the Academy of Nutrition and Dietetics in some states is now the only people that can give nutrition advice unless you are certified by them. Nutrition education is important and older adults must be evaluated to determine if there needs to be changes and to what degree these changes will be followed.

When assessing elder patients' understanding of diabetes and nutrition, a thorough assessment must include individual food preferences, meal preparation capabilities, and potential misunderstandings of adequate nutrition. This should include, but not be limited to dental health, swallowing difficulties, gastrointestinal complaints, decreased appetite, decreased thirst, taste-altering medications, limited finances, and social isolation. Because the diabetes patients are elderly, pushing a fixed number of carbohydrates must be forbidden. Registered dietitians that will not work to the needs and nutrition of elderly patients should not be allowed on a team.

The above is an area of importance for those doing DSME and sometimes they forget about unintentional weight loss as this increases mortality in elderly patients with diabetes. The problem of destructive metabolism is sometimes ignored for these people because acute illness or recent hospitalization is overlooked. Diet moderation, and if medically able, increased physical activity should be considered instead of severe caloric restriction, and should be encouraged in older adults who sincerely wish to lose weight. The goal for individualized planning needs to minimize problems in nutrition management and facilitate changes in eating behaviors. This should be part of the goal to improve clinical outcomes, improved function, and enhance quality of life.

In the elderly, physical activity assessment can be very difficult and should be done in coordination with their doctor. The elderly can often be at increased risk for sedentary lifestyle. This may be caused by recent acute illnesses, coexisting medical conditions such as chronic pain, no safe environment for physical activity, history of falls, and fear of falling. There are many benefits if the elderly diabetes patients are able to exercise, but they should never be forced to exercise. Limited activity exercises need to be investigated when needed and done with their doctor's knowledge.

Other chronic diseases and the number of medications the diabetes patient is taking are important in evaluating potential limitations for the patient. Polypharmacy is the use of several or many medications at the same time. Polypharmacy is always difficult to assess in older patients as many will not tell you what supplements they are taking because they think natural cannot be dangerous. With the conflicts between prescription medications and some supplements, it is important to draw this information out and get them to talk about them. If nothing more, list the supplements that can conflict with the medications you learn they are using.

The fact finding with the elderly can be problematic. Even if the elderly patient is coming to an office and has been instructed to bring all medications and supplements, there is often the doubt that you are seeing all of them. Even for home visits, medications are often hidden and not brought out. Therefore, some detective work must be done. Look for medications from more than one doctor or more than one pharmacy, as this may be a clue to more medications. Always record all information that is on the prescription container, Rx number, date filled, directions, medication name and dosage size, quantity, physician name, refills remaining, and prescription expiration date. Whether you are an educator, peer-to-peer worker, or a peer mentor, dealing with some elderly patients can be a delicate situation where even the best diplomacy may not yield the discovery of all prescriptions and supplements in use.

All conflicts in medication must be reported to the doctor as well as discrepancies like out of date medications, medications not refilled, especially other doctors and pharmacies discovered. Always be on the lookout for duplication of medications and medications that may conflict with other medications.

An additional assessment needs to be done to evaluate patients and their cognitive abilities to understand when medications need to be taken. Look for signs of depression and physical disabilities that may interfere with medication adherence. This can be very important for the elderly with diabetes and using insulin. Pens may become more important than syringes in many cases and in some instances, it may be necessary to suggest or recommend full care facilities.

Based on the discussion above, consider the following practical pointers for DSME in older adults found to have functional limitations:

1. Choose equipment that is easy to hold and easy to use.

2. When possible, simplify the self-care regimen.

3. Conduct education sessions at a slow pace, with instruction occurring in steps. Use educational material that is easy to follow and excludes extraneous information. Schedule multiple sessions, if necessary, to prevent information overload.

4. Provide individual rather than group education.

5. Recommend further evaluation and treatment of depression and cognitive dysfunction before making any diabetes treatment regimen changes.

6. Use memory aids (e.g., personalized handouts) to reinforce points made during face-to-face sessions.

7. Make sure patients understand how to identify hypoglycemia and when to call the provider.

8. Make every effort to minimize the complexity of meal planning and to engage the patient's spouse or others living with the patient in creating a home environment that supports positive dietary change.

9. Prescribe weight loss diets with great caution.

To be continued in part 2.

The Trip to Obtaining Your Medical Records

Now that you are ready to obtain copies of your medical records, make a list of each doctor, period that you were a patient of this doctor, and whether the doctor is still alive or still in practice. Then make a list of medical labs you have used or that your doctors has used, whether they are still in business or not, and locate their address. The purpose is if your doctor is deceased, you may need to contact the labs for test results. Not the best solution, but this may be all that is available to you.

To obtain copies of medical records, you have to be the patient, or the parent of a minor child or the legal guardian of the patient for whom you seek medical records. If you are a caregiver, you may be able to obtain medical records if the patient has provided a legal medical power of attorney to the provider. Verbal authorization generally is not sufficient, but may work for some providers for a limited time. Forget about inquiring or obtaining medical records for your spouse, children of legal age, or parents without legal authorization.

The US Department of Health and Human Services provides background information to help you understand who may, or may not, be able to access your medical records. Providers are required to follow the state rules in which the records are kept. Generally, this means for an adult medical records are kept six or more years. Most children's records are kept three to 10 years beyond the age of 18 or 21. It is always wise to contact the provider to see if the records are still available.

Your doctor or provider is required to share any notes or records they have created or any test results which they have copies. Any information provided to them by another doctor is accessible if that information was used for the diagnosis or treatment being discussed with you. Diagnostic lab tests are a little more complicated, as blood tests, CT scan, x-rays, mammograms, or other tests should be requested from the doctor who ordered them, or from your primary care physician. In most states, the lab will refuse to provide them directly to you. For other records such as hospital records, clinics, or any other medical facility, be sure to request the copies directly from them.

When it involves mental health and related records, this is an area where many doctors will refuse you access. If they do, they must make the reason for denial clear in writing.

Many patients unfortunately believe they or their legal representatives are the only ones that can get copies of their medical records. This is false; there are people that can legally gain access to your medical records without your permission.

When you request copies, most practices, offices, or hospitals will have a form to complete to receive a copies of the requested medical records. They normally will send it to you by fax, email, postal mail, or you may pick it up from the doctor's office. If the facility does not have a specific form, you may write a letter, but be sure to include the following information:

• your name, including your maiden name (if applicable)
• make sure that you date the letter for the date of delivery if possible
• your social security number
• your full date of birth
• your complete address
• your phone number or cell phone number
• the list of record(s) being requested
• the date(s) of service when you were under this doctor's care
• delivery method preferred – pick-up, fax, email, or other method
• your signature

Deliver the letter or mail the letter to the doctor's office. If you deliver, record in your own records the date the date of delivery and it might be beneficial to have a second copy that the person receiving the letter can sign, date, and show their title.

Now we come to the problem of gettingrecords from a doctor that has sold out, merged into another practice, or had simply left the practice (whether died, quit, retired, or another reason).

If your doctor has left the practice or sold the practice or it was combined with another practice, then the new practice should still have your records. If this is the case, follow the same procedure above as if the doctor was still working in that practice.

If your doctor is no longer in practice, or for some reason you cannot locate the doctor or office where you think your records should be, there are some steps you can take to locate your medical records. These steps include:

1. Contact your local medical society. You may be able to look up the phone number online or in the phone book, or you may find the contact information you need through this list of medical societies in each state. You will need to drill down by state to your local society.

Someone at the medical society should be able to let you know what became of your doctor's practice, and will possibly know where the doctor's records are being housed. They may also be able to tell you how to get copies if the procedure will vary from the basic procedure described here.

2. If your local medical society does not have the information you need, then contact your state medical society association, as per the list linked in #1 above.

3. Finally, if the medical societies cannot help you, then begin contacting other practices of the same specialty in your area. Some doctors will ask other practices of the same specialty to house their records when they close their practices. The idea is, that if your doctor is not in business any longer, then the other specialist might want to pick you up as a patient.

Simply call the office of each of the other same-specialty doctors and tell them, "I was a patient of Dr. ____'s. I am hoping to find my medical records. Can you tell me if Dr. _____ gave them to your practice?" If they say yes, then ask their protocol for getting your copies. If they say no, then ask if they know where those records are being kept. If they do not know, then call the next same-specialty practice and ask them the same question.

4. Finally, if none of these possibilities work out, contact the hospitals in your area. Unless you can determine a better department, then try Human Resources. They may know where your records are being kept.

Keep in mind that when your records have been housed elsewhere, they will be difficult to retrieve unless they are among the minority of records that have already been transferred to an electronic health record. For that reason, you will very likely be charged for the copies you want.  Learn more about how much you may have to pay for copies of your medical records.