August 6, 2022

1400H - 1500H
Via Zoom

Empowerment
objective - for
Health Issue laypeople to have an
Course – understanding of the
MEDICAL importance of
RECORDS – generating, keeping
Generate, Keep and archiving
& Archive MEDICAL RECORDS
in their health
management.
 Empowerment
objective - for ROJoson PEP Talk

Health Issue laypeople to have an

I have a Patient
Course – understanding of the Empowerment
MEDICAL importance of Program in which I
RECORDS – generating, keeping like to empower the
Generate, Keep and archiving lay people or
MEDICAL RECORDS patients to take
& Archive
control in the
in their health
management of
management. their health.
 There are 3 courses
in the PEP Talk.
I completed the Core
Course on October 9,
2021.
 From October 23,
2021 onwards, I have
been tackling Health
Disorder and Health
Issue Courses. This
may take 3 years or
longer.
 My PEP TALK today
Empowerment is entitled: MEDICAL
objective - for RECORDS –
Health Issue laypeople to have an Generate, Keep &
Course – understanding of the Archive.
MEDICAL importance of
RECORDS – generating, keeping This is part of the
Generate, Keep and archiving Health Issue Course.
& Archive MEDICAL RECORDS
in their health
management.
 Health Issue Contents of MEDICAL RECORDS – Generate, Keep
Course – & Archive
• What are medical records from laypeople’s
MEDICAL
perspective?
RECORDS – • What are common types of medical records?
Generate, Keep • What are the uses of medical records? Why is it
& Archive important for the laypeople to generate, keep
and archive medical records?
• What are ways of generating medical records?
• What are ways of keeping medical records?
• What are ways of archiving medical records?
• ROJoson advocating statements and advice on
medical records
 Health Issue • What are medical records from laypeople’s
Course – perspective?
MEDICAL Medical records are documents that contain the
RECORDS – history of what transpired in a person’s health
Generate, Keep from birth to death.
& Archive
 Health Issue • What are common types of medical records?
Course –
The documents can be generated by a person
MEDICAL
himself/herself if he/she has the capacity to do it,
RECORDS – such as if he/she is physically and mentally
Generate, Keep functional (to contrast this to a baby, to a person
& Archive with dementia, in coma, etc. who will NOT be
able to do the generation).
 Health Issue • What are common types of medical records?
Course –
If a person is not physically and mentally capable,
MEDICAL
then a guardian has to do the generation of
RECORDS – medical records for the benefit of the former
Generate, Keep (because of the importance of medical records).
& Archive
 Health Issue • What are common types of medical records?
Course –
If a person is physically and mentally capable,
MEDICAL
he/she can and should generate medical records
RECORDS – through a personal journal on the history of
Generate, Keep his/her symptoms or health.
& Archive
He/she can and should be able keep and compile
medical records coming from physicians and other
health care professionals consulted and from
health care institutions such as hospitals,
diagnostic and treatment centers where he/she
receives some form of medical services.
 Health Issue • What are common types of medical records?
Course –
The medical records can be generated in the
MEDICAL
following forms and media:
RECORDS –
 Forms – either handwritten or typewritten
Generate, Keep
 Media – either hard copies or digital copies
& Archive
 Health Issue • What are common types of medical records?
Course –
Specific types of medical records that a person
MEDICAL
can generate, get, keep and archive:
RECORDS –
 Personal health journal
Generate, Keep
 Medical clinic consultation notes from
& Archive
physicians and other health care professionals
 Hospital records when confined
 Diagnostic test results and reports
 Treatment records
 Others
 Health Issue • Sample of personal health journal
Course – Name: Reynaldo O. Joson
MEDICAL Sex: Male
RECORDS – Age: 73 (as of July 31, 2022)
Generate, Keep
& Archive
 Health Issue • Sample of personal health journal
Course – VACCINATION / IMMUNIZATION
MEDICAL Recall:
RECORDS – •Had basic vaccination / immunization when I was
Generate, Keep a baby / child (at least BCG, DPT, Polio, Measles)
•No booster in tetanus toxoid ever since
& Archive
vaccination / immunization at childhood
•No hepatitis B vaccination (2011; 2012; 2013;
2014; 2016 Jan – HBsAg – non-reactive; Anti-HBS-
reactive)
•No flu vaccination
 Health Issue • Sample of personal health journal
Course – VACCINATION /
MEDICAL IMMUNIZATION
RECORDS –
Generate, Keep Anti-COVID19 Vaccination
•March 10, 2021 – Astra
& Archive
Zeneca; June 02, 2021 – Astra
Zeneca
•Booster – December 10, 2021
– Pfizer;  May 24, 2022 –
Moderna 
 Health Issue • Sample of personal health journal
Course – PAST SIGNIFICANT ILLNESS:
MEDICAL Major:
RECORDS – • NO hospitalization ever
Generate, Keep • NO major surgical operation ever
• NO major significant illnesses yet
& Archive
 Health Issue • Sample of personal health journal
Course – PAST SIGNIFICANT ILLNESS:
MEDICAL Minor:
RECORDS – • Excision of epidermal cyst, prepuce (1972 by
Generate, Keep Dr. Serafin Hilvano) – no recurrence up to now
• Excision of warts – knee; toe – Dr. Nelson
& Archive
Cabaluna (circa 2005) – recurred on toe –
applied Duofilm – resolved – no recurrence up
to now
 Health Issue • Sample of personal health journal
Course – PAST SIGNIFICANT ILLNESS:
MEDICAL Minor:
RECORDS – • Plantar fasciitis (late 2014 to 2015 lasting for
Generate, Keep about a year) – disappeared late 2015 after I
did stretching exercises, particular lunges – no
& Archive
recurrence up to now – still doing daily lunge
exercise)
 Health Issue • Sample of personal health journal
Course – PAST SIGNIFICANT ILLNESS:
MEDICAL Minor:
Mucus cyst, right thumb (noted circa 1997; 2012 enlarged
RECORDS – and distended to the point of wanting to rupture
Generate, Keep spontaneously – pricked and aspirated;  recurred at least 2
& Archive times up to Dec 2013; pricked again; recurred July 2014 -
last pricked or aspiration: July 2014 up February 2016 – no
recurrence going 2 years now: recurred May 2016 – 2mm –
steady in size as of July 30, 2016; reaspirated – resolved;
recurred – October 2017 – Reaspirated – Resolved
November 2017 – No recurrence up to now.

Importance of pictures!
 Health Issue • Sample of personal health journal
Course – CURRENT HEALTH STATUS AND CONCERNS:
MEDICAL
RECORDS – Medical conditions present:
Generate, Keep • Carpal tunnel syndrome (more on left hand)
• Mucus cyst, right 4th finger
& Archive • Hypertension (on Amlodipine)
• Benign prostatic hypertrophy (on tamsulosin
and finasteride)

Details can be seen in:

https://rojosonmedicalclinic.wordpress.com/2016/02/24/personal
-medical-records-rojoson-sample/
 Health Issue • Sample of personal health journal
Course – CURRENT HEALTH STATUS AND CONCERNS:
MEDICAL
RECORDS – Overall assessment of current health status and
Generate, Keep concerns:
& Archive
STILL HEALTHY and FUNCTIONAL but with some
not crippling medical conditions
 Health Issue • Sample of personal health journal
Course – RESOLUTIONS ON MAINTAINING HEALTH:
MEDICAL
RECORDS – • Healthy lifestyle – exercise, diet
Generate, Keep • Weight and waist watch
• Medications
& Archive • Etc.
 Health Issue • Sample of medical clinic consultation notes
Course – from physicians and other health care
professionals
MEDICAL
RECORDS –
Generate, Keep
& Archive
 Health Issue • What are ways of generating medical records? A CHALLENGE: almost
Course – all physicians do not
The other way of generating medical records is give patients records
MEDICAL through the documents or records that are of the medical
RECORDS – supposed to be made for you when you have consultation
Generate, Keep health or medical consultations; diagnostic tests; (everything is verbal).
& Archive treatment procedures; hospital confinements;
and other services done by a physician or a health Dr. ROJoson gives!
care provider or a health care institution.

MAKE SURE YOU ASK FOR ALL THESE RECORDS

AND THEN KEEP AND ARCHIVE THEM FOR
FUTURE USE!
 Health Issue • Hospital records when
Course – confined such as Medical
or Clinical Abstract,
MEDICAL
Discharge Summary, etc.
RECORDS –
Generate, Keep
& Archive

• Sample of Clinical Abstract

 Health Issue • Hospital records
Course – when confined
such as Medical
MEDICAL
or Clinical
RECORDS – Abstract,
Generate, Keep Discharge
& Archive Summary, etc.

• Sample of
Discharge
Summary
 Health Issue • What are common types of medical records?
Course –
 Diagnostic test results and reports such as
MEDICAL
blood tests, ultrasound, CT scan, etc.
RECORDS –
Generate, Keep  Treatment records such as operative and
& Archive endoscopic records

 Others – medical certificates

 Health Issue • What are the uses of medical records? Why is it
Course – important for the laypeople to generate, keep
and archive medical records?
MEDICAL
RECORDS – As mentioned, medical records are historical
Generate, Keep records which a person and a health care • PWD ID and
professionals can look back to: benefits
& Archive
 Help manage current health problem especially • Insurance
if there is a relation to the past health problem • Work application
or influence from the past. • Travel
requirements
• Facilitate compliance to organizations which
• School
ask for health history records.
requirements
• Etc.
 Health Issue • What are ways of generating medical records?
Course – Generating medical records means making
MEDICAL medical records
RECORDS – • by yourself via a journal and / or
Generate, Keep • through the documents or records that are
& Archive supposed to be made for you when you have
health or medical consultations; diagnostic
tests; treatment procedures; hospital
confinements; and other services done by a
physician or a health care provider or a health
care institution.
 Importance:
Health Issue • What are ways of generating medical records?
• Facilitate in self-
Course – One way of generating medical records is make a diagnosis and self-
MEDICAL personal journal of your treatment
RECORDS – • health history (from birth to current age) • Facilitate in the
Generate, Keep • current symptoms process of medical
consultations (very
& Archive much appreciated
• Not usually being practiced except for a few
persons who know the importance of this by physicians)
practice. • Facilitate
compliance to
HIGHLY RECOMMENDED TO PRACTICE! organizations
https://rojosonmedicalclinic.wordpress.com/2016/02/24/personal-
which ask for
medical-records-rojoson-sample/ health history
 Health Issue • What are ways of generating medical records? A lot of people do not
Course – take this seriously.
The other way of generating medical records is The consequence is
MEDICAL through the documents or records that are the inconvenience of
RECORDS – supposed to be made for you when you have looking for these
Generate, Keep health or medical consultations; diagnostic tests; records when needed
& Archive treatment procedures; hospital confinements; in the future!
and other services done by a physician or a health
care provider or a health care institution.

MAKE SURE YOU ASK FOR ALL THESE RECORDS AND

THEN KEEP AND ARCHIVE THEM FOR FUTURE USE!
 Health Issue • What are ways of generating medical records? A CHALLENGE: almost
Course – all physicians do not
The other way of generating medical records is give patients records
MEDICAL through the documents or records that are of the medical
RECORDS – supposed to be made for you when you have consultation
Generate, Keep health or medical consultations; diagnostic tests; (everything is verbal).
& Archive treatment procedures; hospital confinements;
and other services done by a physician or a health Dr. ROJoson gives!
care provider or a health care institution.

MAKE SURE YOU ASK FOR ALL THESE RECORDS

AND THEN KEEP AND ARCHIVE THEM FOR
FUTURE USE!
 Health Issue • What are ways of generating medical records? A CHALLENGE: almost
Course – all physicians do not
The other way of generating medical records is give patients records
MEDICAL through the documents or records that are of the medical
RECORDS – supposed to be made for you when you have consultation
Generate, Keep health or medical consultations; diagnostic tests; (everything is verbal).
& Archive treatment procedures; hospital confinements;
and other services done by a physician or a health Dr. ROJoson gives!
care provider or a health care institution.

MAKE SURE YOU ASK FOR ALL THESE RECORDS

AND THEN KEEP AND ARCHIVE THEM FOR
FUTURE USE!
 Health Issue • What are ways of generating medical records? A CHALLENGE: almost
Course – all physicians do not
The other way of generating medical records is give patients records
MEDICAL through the documents or records that are of the medical
RECORDS – supposed to be made for you when you have consultation
Generate, Keep health or medical consultations; diagnostic tests; (everything is verbal).
& Archive treatment procedures; hospital confinements;
and other services done by a physician or a health Dr. ROJoson gives!
care provider or a health care institution.

MAKE SURE YOU ASK FOR ALL THESE RECORDS

AND THEN KEEP AND ARCHIVE THEM FOR
FUTURE USE!
 Health Issue • What are ways of generating medical records? A CHALLENGE: almost
all physicians do not
Course – The other way of generating medical records is give patients records
MEDICAL through the documents or records that are of the medical
RECORDS – supposed to be made for you when you have consultation
Generate, Keep health or medical consultations; diagnostic tests; (everything is verbal).
& Archive treatment procedures; hospital confinements; What to do – ASK!!!
and other services done by a physician or a health If not written copies,
care provider or a health care institution. ask for at least the
diagnosis!
MAKE SURE YOU ASK FOR ALL THESE RECORDS Put into your journal
AND THEN KEEP AND ARCHIVE THEM FOR the verbal
FUTURE USE! explanations of
physicians.
 Health Issue • What are ways of keeping medical records? A lot of people do not
Course – take this seriously.
Keeping medical records means collecting The consequence is
MEDICAL personal medical records and then safekeeping the inconvenience of
RECORDS – them (both the personal journal and the ones looking for these
Generate, Keep given by health care professionals and health care records when needed
& Archive institutions). in the future!

MAKE SURE YOU HAVE A COMPLETE COLLECTION

OF YOUR MEDICAL RECORDS. THEREAFTER,
ENSURE THEY DON’T GET LOST (SAFEKEEP)!
 Health Issue • What are ways of keeping medical records? A lot of people do not
Course – take this seriously.
Keeping medical records means collecting The consequence is
MEDICAL personal medical records and then safekeeping the inconvenience of
RECORDS – them (both the personal journal and the ones looking for these
Generate, Keep given by health care professionals and health care records when needed
& Archive institutions). in the future!

MAKE SURE YOU HAVE A COMPLETE COLLECTION

OF YOUR MEDICAL RECORDS. THEREAFTER,
ENSURE THEY DON’T GET LOST (SAFEKEEP)!
 Health Issue • What are ways of keeping medical records? A CHALLENGE: A lof of
Course – times, physicians get
Keeping medical records means collecting and keep the
MEDICAL personal medical records and then safekeeping diagnostic reports of
RECORDS – them (both the personal journal and the ones patients during
Generate, Keep given by health care professionals and health care consultation and
& Archive institutions). hospital confinement
and do not return
them.
What to do – give
MAKE SURE YOU HAVE A COMPLETE COLLECTION photocopies! Make
OF YOUR MEDICAL RECORDS. THEREAFTER, sure to keep the
ENSURE THEY DON’T GET LOST (SAFEKEEP)! original copies!
 • What are ways of keeping medical records? A CHALLENGE: A lof of
Health Issue times, physicians get
Course – Keeping medical records means collecting and keep the
MEDICAL personal medical records and then safekeeping diagnostic reports of
RECORDS – them (both the personal journal and the ones patients during
Generate, Keep given by health care professionals and health care consultation and
institutions). hospital confinement
& Archive
and do not return
them.
What to do – for films
and other hard copies
MAKE SURE YOU HAVE A COMPLETE COLLECTION of diagnostic tests,
OF YOUR MEDICAL RECORDS. THEREAFTER, make sure they are
ENSURE THEY DON’T GET LOST (SAFEKEEP)! returned to you!
 Health Issue • What are ways of archiving medical records?
Course – Archiving medical records means placing the
MEDICAL collected medical records
RECORDS – • in a specified arrangement system by which
Generate, Keep they can easily be identified and retrieved
& Archive when needed;
• in a specified place where they can easily be
retrievable; and
• with measures to safeguard from privacy issue
and loss.
 • What are ways of archiving medical records? Arrangement by
Health Issue folder system based
Course – Archiving medical records means placing the on:
MEDICAL collected medical records • Dates medical
RECORDS – • in a specified arrangement system by which records generated
Generate, Keep they can easily be identified and retrieved
when needed; • By types of
& Archive
• in a specified place where they can easily be medical records if
retrievable; and serial (with date
• with measures to safeguard from privacy issues arrangement) [Ex:
and loss. series of thyroid
function tests
chronologically
arranged]
 Identify a specific place in
Health Issue • What are ways of archiving medical records? the house or outside the
Course – Archiving medical records means placing the
house where the hard
and soft copies of medical
MEDICAL collected medical records records will be stored
RECORDS – • in a specified arrangement system by which collectively and on a long-
they can easily be identified and retrieved term basis and
Generate, Keep REMEMBER!
& Archive when needed;
• in a specified place where they can easily be For digital copies, identify
where to store and
retrievable; and remember:
• with measures to safeguard from privacy issue • Ipad / Laptop /
and loss. Desktop, etc.
• Cloud (email; blogsite;
etc.)
• USB, external hard
drive, etc.
 Measures against
Health Issue • What are ways of archiving medical records? PRIVACY issue
(KEEP THEM PRIVATE –
Course – Archiving medical records means placing the your call!)
MEDICAL collected medical records
RECORDS – • in a specified arrangement system by which LOSS Issue
Generate, Keep they can easily be identified and retrieved (HAVE A BACK-UP –
& Archive when needed; your call!) [remember!]
• in a specified place where they can easily be Ex:
retrievable; and • Hard copies with soft
• with measures to safeguard from privacy issue copies (digital)
and loss. • Several hard / soft
copies
• Placing the back-ups in
another remote physical
place in case of fire
 Health Issue Samples of techniques in keeping medical records
Course – by patients
MEDICAL
RECORDS –
Generate, Keep
& Archive
 Health Issue Samples of techniques in keeping medical records
Course – by patients
MEDICAL
RECORDS –
Generate, Keep
& Archive
 Health Issue Samples of techniques in keeping medical records
Course – by patients
MEDICAL
RECORDS –
Generate, Keep
& Archive
 Health Issue Samples of techniques in keeping medical records
Course – by patients
MEDICAL
RECORDS –
Generate, Keep
& Archive
 Health Issue Samples of techniques in keeping medical records
Course – by patients
MEDICAL
RECORDS –
Generate, Keep
& Archive
 Health Issue Samples of techniques in keeping medical records
Course – by patients
MEDICAL
RECORDS –
Generate, Keep
& Archive
 Health Issue • ROJoson Advocating Statements and Advice 
Course – Have records of your physical and mental
MEDICAL wellness and illness from birth to the current age
RECORDS – or current time. 
Generate, Keep
& Archive Update these records every 3 years at least or
earlier as indicated.

You can ask a physician to help you organize the

initial comprehensive medical records. 

ROJoson offers such a medical service.

 Health Issue • ROJoson Advocating Statements and Advice 
Course – Ask for copies of medical records from your
MEDICAL attending physicians whenever you seek
RECORDS – consultation; undergo a procedure both
Generate, Keep diagnostic and therapeutic; and whenever you are
& Archive confined in a hospital.
 Health Issue • ROJoson Advocating Statements and Advice 
Course – Keep copies of all results of laboratory, radiologic,
MEDICAL and other medical procedural examinations that
RECORDS – you went through.
Generate, Keep
& Archive
 Health Issue • ROJoson Advocating Statements and Advice 
Course – Don’t leave your medical records to your
MEDICAL physicians without making sure you have the
RECORDS – original copies for your file. 
Generate, Keep
& Archive Records left or given to your physicians may get
lost. It is difficult to ask the physicians for your
medical records that you have left with them
especially when you decide to see a second or
third opinions with other physicians.
 Health Issue • ROJoson Advocating Statements and Advice 
Course – Bring copies of your medical records whenever you see a physician
MEDICAL whether new or previous ones.  Bring the latest records at least. 
RECORDS –
Generate, Keep • New physicians will need your previous records to facilitate the
& Archive medical consultation and treatment. 

• Previous physicians will need your previous records for review to

facilitate the current medical consultation and treatment. 
• Previous physicians may not remember the results and information in
the previous medical consultation and treatment. 
• Previous physicians may not have or may have lost your records in the
previous medical consultation.
 Health Issue • ROJoson Advocating Statements and Advice 
Course – Have digital copies of all your medical records.  Scan paper copies of
MEDICAL existing medical records. 
RECORDS –
Generate, Keep One, digitalizing your records is an efficient way in doing archiving and
& Archive safekeeping. 

Two, digitalizing your records comes in handy during a telemedical

consultation or communication.
 Health Issue • ROJoson Advocating Statements and Advice 
Course – For records disaster preparedness and recovery
MEDICAL program, have a back-up of your medical records
RECORDS – in case one set gets lost. 
Generate, Keep
& Archive Make sure where you place a back-up copy in an
off-site (away from the usual site).
 Health Issue Contents of MEDICAL RECORDS – Generate, Keep Summary
Course – & Archive Take Away
• What are medical records from laypeople’s
MEDICAL
perspective?
RECORDS – • What are common types of medical records?
Generate, Keep • What are the uses of medical records? Why is it
& Archive important for the laypeople to generate, keep
and archive medical records?
• What are ways of generating medical records?
• What are ways of keeping medical records?
• What are ways of archiving medical records?
• ROJoson advocating statements and advice on
medical records
 Health Issue Be always in touch with reliable medical Take Away in
Course – information on the importance of MEDICAL relation to
RECORDS, particularly on how to generate, keep
MEDICAL Patient
and archive.
RECORDS – Empowerment
Generate, Keep Knowledge is power; it gives power.
& Archive Use the 4Ks of Patient Empowerment:
Kaalaman, Kakayanan, Karapatan and
Kapangyarihan
to gain greater control over decisions in
medical management of oneself by
knowing how to generate, keep and
archive medical records.
 Empowerment
objective - for
Health Issue laypeople to have an
Course – understanding of the
MEDICAL importance of
RECORDS – generating, keeping
Generate, Keep and archiving
& Archive MEDICAL RECORDS
in their health
management.