ROJoson PEP Talk: MEDICAL RECORDS - Generate, Keep & Archive

1. Empowerment
objective - for
laypeople to have an
understanding of
the importance of
generating, keeping
and archiving
MEDICAL RECORDS
in their health
management.
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
August 6, 2022
1400H - 1500H
Via Zoom

2. Empowerment
objective - for
laypeople to have an
understanding of
the importance of
generating, keeping
and archiving
MEDICAL RECORDS
in their health
management.
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
ROJoson PEP Talk
I have a Patient
Empowerment
Program in which I
like to empower the
lay people or
patients to take
control in the
management of
their health.

3. There are 3 courses
in the PEP Talk.
I completed the Core
Course on October 9,
2021.

4. From October 23,
2021 onwards, I have
been tackling Health
Disorder and Health
Issue Courses. This
may take 3 years or
longer.

5. Empowerment
objective - for
laypeople to have an
understanding of
the importance of
generating, keeping
and archiving
MEDICAL RECORDS
in their health
management.
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
My PEP TALK today
is entitled: MEDICAL
RECORDS –
Generate, Keep &
Archive.
This is part of the
Health Issue Course.

6. Contents of MEDICAL RECORDS – Generate, Keep
& Archive
• What are medical records from laypeople’s
perspective?
• What are common types of medical records?
• What are the uses of medical records? Why is it
important for the laypeople to generate, keep
and archive medical records?
• What are ways of generating medical records?
• What are ways of keeping medical records?
• What are ways of archiving medical records?
• ROJoson advocating statements and advice on
medical records
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

7. • What are medical records from laypeople’s
perspective?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Medical records are documents that contain the
history of what transpired in a person’s health
from birth to death.

8. • What are common types of medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
The documents can be generated by a person
himself/herself if he/she has the capacity to do it,
such as if he/she is physically and mentally
functional (to contrast this to a baby, to a person
with dementia, in coma, etc. who will NOT be
able to do the generation).

9. • What are common types of medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
If a person is not physically and mentally capable,
then a guardian has to do the generation of
medical records for the benefit of the former
(because of the importance of medical records).

10. • What are common types of medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
If a person is physically and mentally capable,
he/she can and should generate medical records
through a personal journal on the history of
his/her symptoms or health.
He/she can and should be able keep and compile
medical records coming from physicians and other
health care professionals consulted and from
health care institutions such as hospitals,
diagnostic and treatment centers where he/she
receives some form of medical services.

11. • What are common types of medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
The medical records can be generated in the
following forms and media:
 Forms – either handwritten or typewritten
 Media – either hard copies or digital copies

12. • What are common types of medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Specific types of medical records that a person
can generate, get, keep and archive:
 Personal health journal
 Medical clinic consultation notes from
physicians and other health care professionals
 Hospital records when confined
 Diagnostic test results and reports
 Treatment records
 Others

13. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Name: Reynaldo O. Joson
Sex: Male
Age: 73 (as of July 31, 2022)

14. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
VACCINATION / IMMUNIZATION
Recall:
•Had basic vaccination / immunization when I was
a baby / child (at least BCG, DPT, Polio, Measles)
•No booster in tetanus toxoid ever since
vaccination / immunization at childhood
•No hepatitis B vaccination (2011; 2012; 2013;
2014; 2016 Jan – HBsAg – non-reactive; Anti-HBS-
reactive)
•No flu vaccination

15. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
VACCINATION /
IMMUNIZATION
Anti-COVID19 Vaccination
•March 10, 2021 – Astra
Zeneca; June 02, 2021 – Astra
Zeneca
•Booster – December 10, 2021
– Pfizer; May 24, 2022 –
Moderna

16. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
PAST SIGNIFICANT ILLNESS:
Major:
• NO hospitalization ever
• NO major surgical operation ever
• NO major significant illnesses yet

17. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
PAST SIGNIFICANT ILLNESS:
Minor:
• Excision of epidermal cyst, prepuce (1972 by
Dr. Serafin Hilvano) – no recurrence up to now
• Excision of warts – knee; toe – Dr. Nelson
Cabaluna (circa 2005) – recurred on toe –
applied Duofilm – resolved – no recurrence up
to now

18. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
PAST SIGNIFICANT ILLNESS:
Minor:
• Plantar fasciitis (late 2014 to 2015 lasting for
about a year) – disappeared late 2015 after I
did stretching exercises, particular lunges – no
recurrence up to now – still doing daily lunge
exercise)

19. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
PAST SIGNIFICANT ILLNESS:
Minor:
Mucus cyst, right thumb (noted circa 1997; 2012 enlarged
and distended to the point of wanting to rupture
spontaneously – pricked and aspirated; recurred at least 2
times up to Dec 2013; pricked again; recurred July 2014 -
last pricked or aspiration: July 2014 up February 2016 – no
recurrence going 2 years now: recurred May 2016 – 2mm –
steady in size as of July 30, 2016; reaspirated – resolved;
recurred – October 2017 – Reaspirated – Resolved
November 2017 – No recurrence up to now.
Importance of pictures!

20. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
CURRENT HEALTH STATUS AND CONCERNS:
Medical conditions present:
• Carpal tunnel syndrome (more on left hand)
• Mucus cyst, right 4th finger
• Hypertension (on Amlodipine)
• Benign prostatic hypertrophy (on tamsulosin
and finasteride)
Details can be seen in:
https://rojosonmedicalclinic.wordpress.com/2016/02/24/personal
-medical-records-rojoson-sample/

21. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
CURRENT HEALTH STATUS AND CONCERNS:
Overall assessment of current health status and
concerns:
STILL HEALTHY and FUNCTIONAL but with some
not crippling medical conditions

22. • Sample of personal health journal
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
RESOLUTIONS ON MAINTAINING HEALTH:
• Healthy lifestyle – exercise, diet
• Weight and waist watch
• Medications
• Etc.

23. • Sample of medical clinic consultation notes
from physicians and other health care
professionals
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

24. • What are ways of generating medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
The other way of generating medical records is
through the documents or records that are
supposed to be made for you when you have
health or medical consultations; diagnostic tests;
treatment procedures; hospital confinements;
and other services done by a physician or a health
care provider or a health care institution.
A CHALLENGE: almost
all physicians do not
give patients records
of the medical
consultation
(everything is verbal).
MAKE SURE YOU ASK FOR ALL THESE RECORDS
AND THEN KEEP AND ARCHIVE THEM FOR
FUTURE USE!
Dr. ROJoson gives!

25. • Hospital records when
confined such as Medical
or Clinical Abstract,
Discharge Summary, etc.
• Sample of Clinical Abstract
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

26. • Hospital
records when
confined such
as Medical or
Clinical
Abstract,
Discharge
Summary, etc.
• Sample of
Discharge
Summary
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

27. • What are common types of medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
 Diagnostic test results and reports such as
blood tests, ultrasound, CT scan, etc.
 Treatment records such as operative and
endoscopic records
 Others – medical certificates

28. • What are the uses of medical records? Why is it
important for the laypeople to generate, keep
and archive medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
As mentioned, medical records are historical
records which a person and a health care
professionals can look back to:
 Help manage current health problem especially
if there is a relation to the past health problem
or influence from the past.
• Facilitate compliance to organizations which
ask for health history records.
• PWD ID and
benefits
• Insurance
• Work application
• Travel
requirements
• School
requirements
• Etc.

29. • What are ways of generating medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Generating medical records means making
medical records
• by yourself via a journal and / or
• through the documents or records that are
supposed to be made for you when you have
health or medical consultations; diagnostic
tests; treatment procedures; hospital
confinements; and other services done by a
physician or a health care provider or a health
care institution.

30. • What are ways of generating medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
One way of generating medical records is make a
personal journal of your
• health history (from birth to current age)
• current symptoms
• Not usually being practiced except for a few
persons who know the importance of this
practice.
Importance:
• Facilitate in self-
diagnosis and self-
treatment
• Facilitate in the
process of medical
consultations (very
much appreciated
by physicians)
• Facilitate
compliance to
organizations
which ask for
health history
HIGHLY RECOMMENDED TO PRACTICE!
https://rojosonmedicalclinic.wordpress.com/2016/02/24/personal-
medical-records-rojoson-sample/

31. • What are ways of generating medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
The other way of generating medical records is
through the documents or records that are
supposed to be made for you when you have
health or medical consultations; diagnostic tests;
treatment procedures; hospital confinements;
and other services done by a physician or a health
care provider or a health care institution.
A lot of people do not
take this seriously.
The consequence is
the inconvenience of
looking for these
records when needed
in the future!
MAKE SURE YOU ASK FOR ALL THESE RECORDS AND
THEN KEEP AND ARCHIVE THEM FOR FUTURE USE!

32. • What are ways of generating medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
The other way of generating medical records is
through the documents or records that are
supposed to be made for you when you have
health or medical consultations; diagnostic tests;
treatment procedures; hospital confinements;
and other services done by a physician or a health
care provider or a health care institution.
A CHALLENGE: almost
all physicians do not
give patients records
of the medical
consultation
(everything is verbal).
MAKE SURE YOU ASK FOR ALL THESE RECORDS
AND THEN KEEP AND ARCHIVE THEM FOR
FUTURE USE!
Dr. ROJoson gives!

33. • What are ways of generating medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
The other way of generating medical records is
through the documents or records that are
supposed to be made for you when you have
health or medical consultations; diagnostic tests;
treatment procedures; hospital confinements;
and other services done by a physician or a health
care provider or a health care institution.
A CHALLENGE: almost
all physicians do not
give patients records
of the medical
consultation
(everything is verbal).
MAKE SURE YOU ASK FOR ALL THESE RECORDS
AND THEN KEEP AND ARCHIVE THEM FOR
FUTURE USE!
Dr. ROJoson gives!

34. • What are ways of generating medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
The other way of generating medical records is
through the documents or records that are
supposed to be made for you when you have
health or medical consultations; diagnostic tests;
treatment procedures; hospital confinements;
and other services done by a physician or a health
care provider or a health care institution.
A CHALLENGE: almost
all physicians do not
give patients records
of the medical
consultation
(everything is verbal).
MAKE SURE YOU ASK FOR ALL THESE RECORDS
AND THEN KEEP AND ARCHIVE THEM FOR
FUTURE USE!
Dr. ROJoson gives!

35. • What are ways of generating medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
The other way of generating medical records is
through the documents or records that are
supposed to be made for you when you have
health or medical consultations; diagnostic tests;
treatment procedures; hospital confinements;
and other services done by a physician or a health
care provider or a health care institution.
A CHALLENGE: almost
all physicians do not
give patients records
of the medical
consultation
(everything is verbal).
MAKE SURE YOU ASK FOR ALL THESE RECORDS
AND THEN KEEP AND ARCHIVE THEM FOR
FUTURE USE!
What to do – ASK!!!
If not written copies,
ask for at least the
diagnosis!
Put into your journal
the verbal
explanations of
physicians.

36. • What are ways of keeping medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Keeping medical records means collecting
personal medical records and then safekeeping
them (both the personal journal and the ones
given by health care professionals and health care
institutions).
A lot of people do not
take this seriously.
The consequence is
the inconvenience of
looking for these
records when needed
in the future!
MAKE SURE YOU HAVE A COMPLETE COLLECTION
OF YOUR MEDICAL RECORDS. THEREAFTER,
ENSURE THEY DON’T GET LOST (SAFEKEEP)!

37. • What are ways of keeping medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Keeping medical records means collecting
personal medical records and then safekeeping
them (both the personal journal and the ones
given by health care professionals and health care
institutions).
A lot of people do not
take this seriously.
The consequence is
the inconvenience of
looking for these
records when needed
in the future!
MAKE SURE YOU HAVE A COMPLETE COLLECTION
OF YOUR MEDICAL RECORDS. THEREAFTER,
ENSURE THEY DON’T GET LOST (SAFEKEEP)!

38. • What are ways of keeping medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Keeping medical records means collecting
personal medical records and then safekeeping
them (both the personal journal and the ones
given by health care professionals and health care
institutions).
A CHALLENGE: A lof of
times, physicians get
and keep the
diagnostic reports of
patients during
consultation and
hospital confinement
and do not return
them.
MAKE SURE YOU HAVE A COMPLETE COLLECTION
OF YOUR MEDICAL RECORDS. THEREAFTER,
ENSURE THEY DON’T GET LOST (SAFEKEEP)!
What to do – give
photocopies! Make
sure to keep the
original copies!

39. • What are ways of keeping medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Keeping medical records means collecting
personal medical records and then safekeeping
them (both the personal journal and the ones
given by health care professionals and health care
institutions).
A CHALLENGE: A lof of
times, physicians get
and keep the
diagnostic reports of
patients during
consultation and
hospital confinement
and do not return
them.
MAKE SURE YOU HAVE A COMPLETE COLLECTION
OF YOUR MEDICAL RECORDS. THEREAFTER,
ENSURE THEY DON’T GET LOST (SAFEKEEP)!
What to do – for films
and other hard copies
of diagnostic tests,
make sure they are
returned to you!

40. • What are ways of archiving medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Archiving medical records means placing the
collected medical records
• in a specified arrangement system by which
they can easily be identified and retrieved
when needed;
• in a specified place where they can easily be
retrievable; and
• with measures to safeguard from privacy issue
and loss.

41. • What are ways of archiving medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Archiving medical records means placing the
collected medical records
• in a specified arrangement system by which
they can easily be identified and retrieved
when needed;
• in a specified place where they can easily be
retrievable; and
• with measures to safeguard from privacy issues
and loss.
Arrangement by
folder system based
on:
• Dates medical
records generated
• By types of
medical records if
serial (with date
arrangement) [Ex:
series of thyroid
function tests
chronologically
arranged]

42. • What are ways of archiving medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Archiving medical records means placing the
collected medical records
• in a specified arrangement system by which
they can easily be identified and retrieved
when needed;
• in a specified place where they can easily be
retrievable; and
• with measures to safeguard from privacy issue
and loss.
Identify a specific place in
the house or outside the
house where the hard
and soft copies of medical
records will be stored
collectively and on a long-
term basis and
REMEMBER!
For digital copies, identify
where to store and
remember:
• Ipad / Laptop /
Desktop, etc.
• Cloud (email; blogsite;
etc.)
• USB, external hard
drive, etc.

43. • What are ways of archiving medical records?
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Archiving medical records means placing the
collected medical records
• in a specified arrangement system by which
they can easily be identified and retrieved
when needed;
• in a specified place where they can easily be
retrievable; and
• with measures to safeguard from privacy issue
and loss.
Measures against
PRIVACY issue
(KEEP THEM PRIVATE –
your call!)
LOSS Issue
(HAVE A BACK-UP –
your call!) [remember!]
Ex:
• Hard copies with soft
copies (digital)
• Several hard / soft
copies
• Placing the back-ups in
another remote physical
place in case of fire

44. Samples of techniques in keeping medical records
by patients
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

45. Samples of techniques in keeping medical records
by patients
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

46. Samples of techniques in keeping medical records
by patients
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

47. Samples of techniques in keeping medical records
by patients
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

48. Samples of techniques in keeping medical records
by patients
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

49. Samples of techniques in keeping medical records
by patients
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive

50. • ROJoson Advocating Statements and Advice
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Have records of your physical and mental
wellness and illness from birth to the current age
or current time.
Update these records every 3 years at least or
earlier as indicated.
You can ask a physician to help you organize the
initial comprehensive medical records.
ROJoson offers such a medical service.

51. • ROJoson Advocating Statements and Advice
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Ask for copies of medical records from your
attending physicians whenever you seek
consultation; undergo a procedure both
diagnostic and therapeutic; and whenever you are
confined in a hospital.

52. • ROJoson Advocating Statements and Advice
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Keep copies of all results of laboratory, radiologic,
and other medical procedural examinations that
you went through.

53. • ROJoson Advocating Statements and Advice
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Don’t leave your medical records to your
physicians without making sure you have the
original copies for your file.
Records left or given to your physicians may get
lost. It is difficult to ask the physicians for your
medical records that you have left with them
especially when you decide to see a second or
third opinions with other physicians.

54. • ROJoson Advocating Statements and Advice
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Bring copies of your medical records whenever you see a physician
whether new or previous ones. Bring the latest records at least.
• New physicians will need your previous records to facilitate the
medical consultation and treatment.
• Previous physicians will need your previous records for review to
facilitate the current medical consultation and treatment.
• Previous physicians may not remember the results and information in
the previous medical consultation and treatment.
• Previous physicians may not have or may have lost your records in the
previous medical consultation.

55. • ROJoson Advocating Statements and Advice
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Have digital copies of all your medical records. Scan paper copies of
existing medical records.
One, digitalizing your records is an efficient way in doing archiving and
safekeeping.
Two, digitalizing your records comes in handy during a telemedical
consultation or communication.

56. • ROJoson Advocating Statements and Advice
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
For records disaster preparedness and recovery
program, have a back-up of your medical records
in case one set gets lost.
Make sure where you place a back-up copy in an
off-site (away from the usual site).

57. Contents of MEDICAL RECORDS – Generate, Keep
& Archive
• What are medical records from laypeople’s
perspective?
• What are common types of medical records?
• What are the uses of medical records? Why is it
important for the laypeople to generate, keep
and archive medical records?
• What are ways of generating medical records?
• What are ways of keeping medical records?
• What are ways of archiving medical records?
• ROJoson advocating statements and advice on
medical records
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Summary
Take Away

58. Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive
Take Away in
relation to
Patient
Empowerment
Knowledge is power; it gives power.
Use the 4Ks of Patient Empowerment:
Kaalaman, Kakayanan, Karapatan and
Kapangyarihan
to gain greater control over decisions in
medical management of oneself by
knowing how to generate, keep and
archive medical records.
Be always in touch with reliable medical
information on the importance of MEDICAL
RECORDS, particularly on how to generate, keep
and archive.

59. Empowerment
objective - for
laypeople to have an
understanding of
the importance of
generating, keeping
and archiving
MEDICAL RECORDS
in their health
management.
Health Issue
Course –
MEDICAL
RECORDS –
Generate, Keep
& Archive