建立个人医疗记录的3个步骤

三步骤建立个人病历
3 Steps to Building a Personal Medical Record
August 25, 2016 · Amy Thompson

A personal medical record is a compilation of all your medical information, including test results, treatment reports, and notes written by your health care team. While each office and facility keeps a record of your care, it’s important to have a complete file for your own use, so you can share it with a new doctor, review at home to better understand your treatment, or manage your health insurance claims, taxes, and other legal matters. Here is what to include, how to compile it, and the best ways to organize it and store it for safekeeping.
个人医疗记录是一个编译所有的医疗信息，包括测试结果，治疗报告，并由你的医疗保健团队写的笔记。虽然每个办公室和设施都记录你的护理记录，有一个完整的文件为你自己使用是很重要的，所以你可以与一个新的医生分享，在家里的复查，以更好地了解你的治疗，或管理你的健康保险索赔，税收和其他法律事务。以下是包括，如何编译它，最好的方式来组织，并将其存放保管。

Step 1. What to include
步骤1.包括什么
A complete personal medical record should include the following information:
一个完整的个人医疗记录应包括以下信息：

Your diagnosis, including the specific cancer type and stage
您的诊断，包括特定的癌症类型和阶段

Date you were diagnosed
你被诊断的日期

Copies of diagnostic test results and pathology reports
诊断性试验结果和病理报告的复印件

Complete treatment information, such as chemotherapy drug names and doses, sites and doses of radiation therapy
完整的治疗信息，如化疗药物名称和剂量，位置和剂量的放射治疗

Start and end dates for all treatments
所有治疗的开始和结束日期

Results of treatment and any complications or side effects
治疗结果和任何并发症或副作用

Information about palliative care, including medications for pain management, nausea, or other side effects
关于姑息治疗的信息，包括疼痛管理，恶心，或其他副作用的药物

A schedule for follow-up care
后续护理计划

Contact information for the doctors and treatment centers involved in your diagnosis and treatment, as well as others who have cared for you in the past, such as your family doctor
医生和治疗中心的联系信息，包括你的诊断和治疗，以及其他人谁照顾你在过去，如你的家庭医生

Dates and details of other major illnesses, chronic health conditions, and hospitalizations
其他重大疾病的日期和细节，慢性疾病，和住院治疗

Family medical history
家族病史

Details of past physical exams, including cancer screening tests and immunizations
过去体检的详细信息，包括癌症筛查试验和免疫接种

Step 2. How to compile your personal medical record
步骤2.如何编写你的个人医疗记录
Keeping track of your medical records might feel like a huge task, but it’s worth it in the long run. The American Society of Clinical Oncology (ASCO) offers cancer treatment plans and summaries that can help keep track of information about your diagnosis and treatment.
跟踪您的医疗记录可能会觉得像一个巨大的任务，但它是值得的，从长远来看。美国临床肿瘤学会（ASCO）提供癌症治疗计划和总结，可以帮助保持跟踪你的诊断和治疗信息。

Compiling this information on an ongoing basis will create a complete and easily accessible view of your health. Remember these strategies to help you collect the latest copies of your records:
在正在进行的基础上编译这一信息将创建一个完整的和方便的查看您的健康。记住这些策略，以帮助你收集你的记录的最新副本：

When you have a diagnostic test or procedure, ask for a copy of the results or report
当你有一个诊断测试或程序，要求一份结果或报告的副本

At each appointment, ask your doctor or nurse for a copy of anything new that’s been added to your file or electronic medical record
在每一个预约，请询问您的医生或护士对一个已经添加到您的文件或电子病历的任何新副本

If you spent time in the hospital, ask for a copy of your records when you’re discharged
如果你在医院里呆了一次，当你出院时，要求一份结果或报告的副本

Keep copies of your medical bills and insurance claims as they occur
保存你的医疗帐单和保险索赔的副本

Talk to your doctor if you need help figuring out which records to include
告诉你的医生，如果你需要帮助找出包括哪些记录

If collecting this information feels overwhelming, ask your friends or family for help. While you have to sign off on any requests for personal medical information, they can fill out forms or make phone calls for you.
如果收集这些信息感到不知所措，请你的朋友或家人寻求帮助。当你必须在任何对个人医疗信息的要求上签字的时候，他们可以填写表格或打电话给你。

Step 3. Organizing and storing your personal medical record
步骤3.组织和存储你的个人医疗记录
There are different ways to organize your medical records. To help figure out what works best for you, talk to other cancer survivors about what they have done, or visit a local office supply store to see what sort of organizers are available. Here are a few options:
有不同的方法来组织你的医疗记录。为了帮助找出最适合你的，和其他癌症幸存者谈论他们所做的，或访问一个当地的办公用品商店，看看有什么样的组织者是可用的。这里有几个选项：

Use a filing cabinet, 3-ring binder, or desktop divider with individual folders
使用文件柜，三环粘结剂，或桌面分压器与个人文件夹

Store files on a computer, where you can scan and save documents or type up notes from an appointment
存储在计算机上的文件，在那里您可以扫描和保存文档或从预约中键入笔记

Store records online using an e-health tool; certain online records tools may be accessed, with permission, by doctors or family members
存储记录在线使用电子健康记录的工具；某些在线工具可允许的，由医生或家庭成员

Organize your records by date or by categories, such as treatments, tests, doctor appointment, etc.
通过日期或类别组织你的记录，如治疗、测试、医生预约等。

However you decide to store your personal medical record, be sure to keep them in a secure location, like a safe deposit box, fireproof home safe, or password-protected files. If you decide to use an online service, carefully check the security and confidentiality measures the company uses to protect your information. A family member or friend could also keep a copy in case of emergency.
然而，你决定存储你的个人的医疗记录，一定要保持他们在一个安全的位置，像一个安全的保险柜，安全防火，或密码保护的文件。如果你决定使用一个在线服务，仔细检查公司使用的安全和保密措施，以保护您的信息。在紧急情况下，一个家庭成员或朋友也可以保留一份。