Keeping the Records Straight

Your battle with cancer is about more than just your treatment!

You will also be faced with a mountain of paperwork! You must start saving important records and organising them in a special “medical records” file. These records will save a lot of time, stress and expense in the future.

Your medical records are also essential if you transfer to a new doctor or hospital or if the records being kept by your doctor / hospital are lost. They will also help with medical aid claims, taxes and other legal matters such as disability insurance and life insurance.

If you have a recurrence your old records will help your healthcare practitioner to make decisions.

Access to records

In provincial hospitals records are kept by the superintendent. Access is subject to compliance with the requirements of the Access to Information Act or such conditions as may be approved by the superintendent.

According to the HCPSA, medical practitioners must provide adults with a copy of (or abstract or direct access to) their own records upon request. For minors the parent or legal guardian must apply.

Medical practitioners, or dentists, must not provide information to a third party without your written authorization except:

  When they are a witness in a legal trial between you and a third party.

  When you have instituted court action and they are ordered to testify on your medical condition.

  If you sue them and they testify in their own defense.

  When the Medical Professions Board institutes disciplinary proceedings and they have to answer to a charge.

  When they are of the opinion that the information ought to be divulged, in the interest of the general public.

How to access records

When you go for tests or procedures ask for a copy of the test results and / or procedure report.

At each visit to the doctor ask for a copy of anything new on your medical record. You may also want to write your own notes detailing what happened at every appointment.

If you spend time in hospital, ask for a copy of your medical record for when you leave. If you have already finished treatment it is not too late to compile records. Ask your healthcare practitioners for copies of your records.

What to keep

Medical Information

1.Medical History

a. Dates of diagnoses

b. The diagnosis:

  The name of your type of cancer.

  Is it BrCa1 or BrCa2 or Her2 or   

     Hormone Receptor-Positive.

  The stage and what grade it is.

  Remember to include where  your cancer is located (a simple drawing will usually work) and, if it has spread, where.

c. Medical Reports

  Pathology and lab test reports.

  Diagnostic results such as biopsies,   

     scans, x-rays, MRIs, etc.

2.Treatments & Medications

a. The names and dosages of drugs you receive. Record dosages of chemotherapy, as well as sites, and dosages for radiation therapy.

b. Information on other care including pain or nausea medication, drugs or procedures to treat side effects, occupational therapy or nutritional support.

c. The results of treatments received and whether you experienced any complications or side effects.

3. The name and contact details of ALL   the doctors treating you such as:

General Practitioner

Hospitals

Nurses

Oncologist

Physical and occupational therapists,

Physiologist/ psychiatrist

Radiologist

Social workers

Surgeons

Employment Benefits

Employment contract

Company disability policies

Leave entitlements

Insurance Policies

Medical and hospital insurance

Medical Aid rules

Life insurance

Long-term disability insurance

Short-term disability insurance

Workers’ compensation insurance

General Documents

Invoices for medical or treatment related expenses

Receipts for payments you made

Personal financial records

A Will. You should specify:

Who is to receive your assets

What beneficiaries will receive and when

How the distribution of your assets is to be done

Who you want as the guardian(s) of your children.

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