A document reference is a record of any medical document related to your care - lab results, imaging reports, discharge summaries, care plans, or other important healthcare documents.

These documents help your healthcare team access important information about your health history, test results, and treatment plans all in one place.

Note: You can view your medical documents but cannot edit most details. Your healthcare providers manage document information to ensure accuracy.

 

Types of Medical Documents

Test results and reports:

  • Lab results (blood work, urine tests, cultures)
  • Imaging reports (X-rays, CT scans, MRIs, ultrasounds)
  • Pathology reports (biopsy results, tissue analysis)
  • Cardiac tests (EKG, echocardiogram, stress test results)

Care documentation:

  • Discharge summaries from hospital stays
  • Consultation reports from specialists
  • Treatment plans and care instructions
  • Medication lists and prescriptions

Administrative documents:

  • Insurance forms and authorizations
  • Referral letters to specialists
  • Medical certificates and clearances
  • Advance directives and healthcare proxies

 

Understanding Your Document Information

Basic document details:

  • Document type: What kind of document it is
  • Category: The general classification (lab result, imaging, etc.)
  • Status: Current state (current, superseded, entered-in-error)
  • Date: When the document was created
  • Description: Brief explanation of what the document contains

Document content:

  • Attachments: The actual document files (PDFs, images, etc.)
  • Related documents: Other documents connected to this one
  • Context: When and where the document was created

Document status meanings:

  • Current: The most up-to-date version
  • Superseded: Replaced by a newer version
  • Entered-in-error: Added by mistake

 

How to Use Your Medical Documents

Review regularly:

  • Check for new test results and reports
  • Read through important documents like discharge summaries
  • Look for any documents you don't recognize or understand
  • Note any documents marked as "superseded" - newer versions may be available

Share with healthcare providers:

  • Bring relevant documents to appointments
  • Share test results with specialists
  • Provide documents to new healthcare providers
  • Reference documents when discussing your health history

Keep organized:

  • Download important documents for your personal records
  • Keep copies of key documents like medication lists
  • Organize documents by type or date for easy reference
  • Share important documents with family members or caregivers

 

Questions to Ask About Your Documents

About test results:

  • "What do these test results mean?"
  • "Are these results normal or concerning?"
  • "Do I need any follow-up tests?"
  • "How do these results compare to my previous tests?"

About reports and summaries:

  • "Can you explain what this report says?"
  • "What are the next steps based on this document?"
  • "Should I share this with my other doctors?"
  • "Are there any important instructions I should follow?"

About document management:

  • "How often will I receive new documents?"
  • "How long are documents kept in my record?"
  • "Can I get copies of my documents?"
  • "Who else has access to these documents?"

Your medical documents are an important part of your healthcare record. Understanding them helps you stay informed and engaged in your care.