Bring the ER records: getting your paperwork to the first visit

Key takeaways

• Bring the discharge paperwork you were handed. It is the fastest record you have.
• For the full visit notes and imaging reports, check the hospital's patient portal first, then its health information or medical records department.
• Federal law gives you the right to a copy of your health record. HealthIT.gov says a provider can take up to 30 days, with up to 30 more if needed, so start early.
• Ask for the specific pieces you need: visit notes, imaging reports, and the images themselves if a scan was done.

A lot of metro crashes go in this order: an ambulance or a ride to an emergency department on the night of the wreck, clear imaging, a diagnosis of a sprain or strain, instructions to follow up, and then an injury clinic within the week. The desk's emergency room or injury clinic guide explains why that order is normal. This guide covers the handoff between the two buildings, which is paper.

Why the clinic wants the ER's paperwork

The emergency department's job is to rule out what can kill you. Whatever it checked, whether a CT of the head, X-rays of the neck, or a neurological exam, is information the next clinician should not have to guess at. It shapes where they look and what they skip. It also sets a date: this is what was found the night of the crash. The desk's page on the dated exam record explains why that first date matters to every clinician who comes after.

Step one: what you already have

Look for the discharge packet. Most people get one and most people lose it in the car. It usually includes the diagnosis, any prescriptions, follow-up instructions, and sometimes a summary of tests. Photograph every page tonight. Bring the paper to the first visit.

If a scan was done, check whether you were given a disc or a card with a way to view images. Some hospitals hand one out, many do not.

Step two: the patient portal

HealthIT.gov's guide to getting your health record puts this first: check your provider's online patient portal, if they have one. Most large health systems in the metro, on both sides of the river, have one. Your account may have been created during registration, or you may need to sign up with information from the discharge papers.

In the portal, look for:

• Visit notes or after-visit summary for the emergency department encounter.
• Imaging results, which usually means the radiologist's written report.
• Test results from any labs.

Notes and reports can take a few days to post. Download or print what is there, and check back.

Step three: the records department

If the portal does not have what you need, HealthIT.gov suggests the provider's website for contact details, or calling or visiting its health information services department, often called medical records. Some practical points for the request:

1. Be specific. HealthIT.gov notes you can ask for a full record or a partial one. For a crash follow-up, ask for the emergency department visit notes and any imaging reports from that date. Ask separately for a copy of the images if you want them.
2. Pick a format. The same guide lists options including electronic files, the portal, email, a CD or USB drive, fax, mail and pickup.
3. Ask about timing. HealthIT.gov says a provider can take up to 30 days to deliver your record and may request up to 30 more. Many are faster, but do not wait on the records to book the exam.
4. Ask about cost. The guide says electronic copies are likely free, and a provider may charge a reasonable fee for the cost of making or mailing copies.

If you went to an urgent care instead, the same steps apply. If you were seen at a hospital in Illinois, the process is the same idea. The federal right to your record does not change at the river.

Step four: sending it to the clinic

You can bring copies yourself, which is usually fastest. Or ask the clinic at your first visit how it prefers to receive outside records and whether it can request them with your written permission. The desk does not publish the clinic's records process, because the clinic does not publish it. Ask on the call.

Do not wait for the paper

The biggest mistake here is treating the records as a prerequisite. They are not. Book the exam this week with whatever you have in hand, the discharge packet or even just the name of the hospital and the date. Tell the clinician what you remember being told. Records can follow. The week, which is the part with a clock on it, cannot be recovered later.

Discharged and still hurting? Bring the packet. Start with an exam. Hazelwood (314) 627-1411, Tesson Ferry (314) 530-5480, O'Fallon (636) 280-0990. All three close 12 to 2 daily.

If anything on the emergency list appears after discharge, such as a headache that keeps getting worse or new vomiting, go back to an emergency room. Everything on this desk is educational, not medical or legal advice.