Here’s a situation that comes up for many people: you move in later life.
Or maybe it’s your older mother — or father, or other older relative — who’s moving to a new town, perhaps to be closer to you, or otherwise be somewhere more conducive to aging in place.
Such a move means that you’ll need to establish care with a new primary care provider.
For most older adults, establishing a good working relationship with a new health provider is a challenge. If nothing else, it can take some time to feel that each party knows and understands the other.
But it’s also in many cases a terrific opportunity to review a person’s health and healthcare. Provided, of course, that everyone involved makes an effort, and has good information to work with.
In this post, I’ll share my list of the most useful medical records and health information that you should bring to that first visit with the new primary care provider.
Do you have to bring this information? Of course not. In my own experience, most people bring nothing more than a medication list, if that. And they leave it to the new doctors to request health information from the previous doctors, which often arrives well after that first new patient visit.
But this is a problem, because it makes it quite difficult for that first visit to be truly useful.
Sure, the doctor can interview you, and do a physical exam. Yet for many older adults, that interview and exam is often much more productive if a doctor can combine it with a review of the most useful health information.
I myself used to see a fair number of new older patients, when I was a primary care geriatrician at the Over 60 Health Center. Those first visits often felt like fumbling around in a dark room, feeling the walls and furniture and trying to get a sense of the overall layout.
But occasionally, a new patient would come with useful health information in hand. This generally made a big difference in how quickly we could ensure that our new patient was getting the right medical care from us, and from other involved doctors.
So if you want to have the best start possible with a new doctor — or help your aging parent do so — you’ll need to do a little advance preparation. This often requires some time and energy. But it will pay off, by ensuring that the new doctor has the information he or she needs, to provide you with good healthcare.
Also, if you are in that season of life where you’re starting to be more involved with your aging parent’s health (or think perhaps you should be), this is a great opportunity to learn more about your parent’s health.
10 Useful Types of Medical Information to Bring to a New Primary Care Provider
Here’s my list of what I ask patients and families to bring to me, in order to make that new patient visit most useful.
This list is especially suited to the primary care of aging adults with chronic medical problems. But most of this information can come in handy for first visits with specialists. It can also be very useful to clinicians in the emergency room, or at urgent care.
Note: If you or your loved one have been maintaining a personal health record, this is the type of information that I hope you’ve been keeping in your personal health record!
1. List of chronic health conditions.
This would include any conditions that you currently see a doctor for, or is being monitored. Bonus points if you include the year the condition was first diagnosed, or any other major milestones related to the disease. You can also include major past problems which are no longer being actively treated.
Now, electronic medical records and patient portals often generate a list of conditions automatically. But these tend to be long, unwieldy, and cluttered with diagnoses that may or may not be still relevant. So be sure to keep a list based on what your previous PCP had been focused on.
2. Medication list.
Be sure to list all prescribed medications, along with any over-the-counter medications and dietary supplements. Also helpful:
- Highlight any new or recently started medications;
- List any recently stopped medications (e.g. from the past 6 months);
- List any medications you believe have been problematic in the past.
3. Laboratory results.
Most commonly these are results from blood tests and urine tests. Any lab results from the past 1-2 years will be helpful. You can learn about the tests that are ordered often in older adults here: Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults.
- Specific tests that are likely to be useful include:
- Complete blood count (CBC)
- Electrolyte panel, which usually includes sodium, potassium, chloride, CO2
- Renal panel, which usually includes creatinine and blood urea nitrogen (BUN)
- Thyroid function tests, such as thyroid-stimulating hormone (TSH) and/or free thyroxine (FT4)
- Urine analysis
- Do bring any lab results you have. It is useful to see what other doctors have ordered and checked.
- Do bring results from different dates if at all possible. Lab results are much more useful when a trend or context can be evaluated. In many cases, comparing the latest results to previous results is extremely useful.
4. Radiology and imaging results.
This includes x-ray reports, ultrasound reports, CT scans, MRIs, etc. Radiology medical records from the last 1-5 years are especially useful.
5. Other medical diagnostic reports.
These might include pulmonary function tests, EKGs, cardiac catheterization reports, biopsy results, neuropsychology evaluations, and so forth. It’s especially useful to have medical reports that are related to the diagnosis or management of a current chronic condition.
6. Hospital and emergency department reports.
Try to get a copy of the narrative reports that clinicians create when a person comes the emergency room, or is hospitalized. These medical records are the reports that are written by health providers, for other health providers. Note: these are not same reports as the patient discharge instructions that are always handed out.
You may have to file a medical records request to obtain the medical records that are most useful. You do have a right to obtain your own records upon written request, or your power of attorney for healthcare can do so, as I explain in this article about HIPAA. However, some agreeable clinicians will just print them out in the office for you, if they have online access to them.
Specific examples of useful reports include:
- Emergency room clinical note. This is the note dictated (or typed) by the emergency room doctor who managed your loved one’s visit.
- Hospital Admission History & Physical. This is the note dictated by the admitting doctor, when a person is initially admitted to the hospital.
- Hospital Discharge Summary. This is the note dictated by a discharging clinician, when a person is discharged to home or rehabilitation. It usually summarizes the patient’s hospital course.
7. List of involved clinicians.
List the doctors and healthcare providers who were previously involved in your loved one’s care. I often learn about important problems by finding out just why a person was seeing a given specialist.
For each specialist, it’s helpful to know when you established care, and how often you’d been seeing each provider. Your list might include:
- Primary care provider
- Medical specialists, such as cardiologists, pulmonologists, urologists, neurologists, etc.
- Behavioral medicine clinicians, such as psychologists, counselors, and therapists
- Skilled nursing facility doctors, if relevant (for instance, if your aging parent is currently at the facility, or recently was discharged)
- Other skilled medical therapists, such as for physical, occupational, or speech therapy
- Any other health professional who is significantly involved in you or your parent’s care
8. Clinical visit notes.
Visit notes written by the primary care doctor, and the medical specialists, can be useful. At a minimum, try to get a copy of the last note.
I recommend starting by requesting notes from the last 3 visits, or the last year. If it’s easy to get more notes from each provider, you can do so as well.
If your previous doctors had a patient portal, check to see if the complete visit notes are available there, as some major health systems have begun making clinical visit notes available in this way.
Again, HIPAA gives patients (and their legally designated surrogates) the right to obtain their medical records upon request.
9. List of other providers of supportive or eldercare services.
Have you or your loved one been getting help from a care manager? In-home aides? A patient navigator? A good primary care provider should be interested in knowing who has been involved, and what kind of help they’ve been providing. (Learn more about eldercare options here: Providing Elder Care: Covering the Cost of Home Care, Assisted Living & Other Options.)
10. Advance care planning documents.
These include any durable power of attorney documents, advance directives, living wills, pre-hospital DNRs, and/or POLST (Physician Orders for Life-Sustaining Treatment) forms.
How a Personal Health Record Can Help
Long list, eh? Well, you probably won’t be surprised to hear that so far, I’ve had very few patients arrive with most of this information.
But this is the medical information that we doctors should know, in order to provide you or your aging parent with good care.
The ideal process, of course, is to collect medical information into some kind of personal health record system as you go along, so that you have all the information handy if you ever need to switch doctors. If you currently have a patient portal, that’s great but usually it only holds information from one particular practice, and you might lose access if you leave the practice. For this reason, it’s good to keep your own copy of your medical records, separate from the online patient portals.
So for instance, every time you or your loved one gets a blood draw, you would ask to get a copy of the results (or download them from your patient portal), and then you would file these results in your paper or digital personal health record. (For more on how to maintain a personal health record, see this post.)
But if you haven’t been maintaining a personal health record, a switch to a new primary care provider is the perfect time to start one.
So if you have the time, energy, and interest in being proactive, gather up these medical records and bring them to that new patient visit. Your new provider will thank you, and you or your older loved one should be able to get better healthcare.
This article was reviewed and updated by Dr. Kernisan in January 2024.