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Personal Health Records: Tracking Medical Treatment and Needs

Updated on September 26, 2012

My mother recently had a sudden illness that landed her in the hospital without warning. For about ten days, she was unable to understand or communicate her health care needs, or have viable conversations with hospital staff. As her only child, I knew it was up to me to keep track of her treatment, ask questions of the nurses and doctors, and in general keep track of her medical care while she could not.

My mother has always been very independent, so I was not used to having being this involved in her medical care. While I wanted to do it, I was quickly overwhelmed by the amount of information I needed to track! From doctors' advice to test results to how much she ate for breakfast, I quickly learned that I couldn't count on my memory for something this important.

Out of necessity, I began jotting down notes in a notebook to remind myself of what the nurses, doctors, and aides told me each day. I also began noting phone calls I received when I wasn't at the hospital, so that I could remember what was said. These notes were especially helpful when, after a long day and night at my mom's side, I was too tired to remember it all. This health care notebook became my mother's health record and her best advocate throughout her hospital stay.

Medical Treatments are Difficult to Track
Medical Treatments are Difficult to Track | Source
What is in a personal health record?
What is in a personal health record? | Source

What is a Health Care Notebook?

A health care notebook, also known as a personal health record, is a complete record of the health, treatment, medication, and consultation surrounding an individual person. Health care notebooks serve as a method for tracking all information in one place as a reference both for the patient and for their caregivers.

This information can be stored in many ways, but I have found that a three-ring binder with pockets and sheet protectors for important papers works well. The notebook can also be kept electronically, as long as you are able to access all part of it using a mobile device at your appointments.

Health care notebooks are especially helpful for patients with complex medical conditions, elderly patients, or patients with cognitive impairments. Having everything in one place to reference can literally save a life.

Why Should I Have a Health Care Notebook?

There are many reasons to keep a health care notebook. As noted above, it is especially helpful for caregivers of people who are unable to keep accurate and complete records of their own medical treatment. But if you don't fit into that category, why should you have one? Ask yourself the following questions:

If a sudden illness or accident ever happens, would my family have easy access to my medical records, such as my doctors' information, prescriptions and other medications I take, and chronic conditions?

If I were hospitalized or needed a skilled nursing facility, how quickly would the hospital staff be able to gather all of my medical information?

If either of these questions caused you to pause, you should keep a health care notebook.

What Should Be in a Health Care Notebook?

Once you decide that you need a health care notebook for you or for someone else, what do you put into it? The short answer is everything! It's better to have information that you don't need than to be missing something when you need it.

Here is a checklist of what should always be included:

  • Contact information for health care providers (doctors, clinics, etc.), including phone numbers, contact names, and addresses
  • Insurance information (member ID, group number, and contact information)
  • Pharmacy information
  • Contact information for family members
  • Appointment calendar
  • Medication list, including both prescription and over-the-counter medications
  • Allergy documentation
  • Any relevant medical history, such as surgeries (with dates)
  • Contact log of all conversations with medical staff
  • List of questions for your next call or conversation with medical staff

The more information you have in the health care notebook, whether it is for you or someone else, the better!

Some other information that could be useful:

  • Copies of lab reports
  • Copies of test results
  • Copies of medical notes
  • Notes regarding past appointments
  • Contact information for past doctors or medical staff.

Medical Records
Medical Records | Source

What Do I Write When I Talk to Medical Staff?

For each conversation that you have with a doctor, nurse, or other staff at a medical practice, you should keep a contact log. A contact log can be a formal sheet that you complete each time, or it can be just your notes from the conversation. Regardless of its formality, it should be legible and understandable by others (no uncommon abbreviations or shorthand). Here are the elements of a useful contact log:

  • Date and time of conversation
  • Location of conversation if in person, or "phone" if it was a phone call
  • Name and title of person you spoke with. If you left a message, note who you left a message with (or on whose voicemail)
  • Reason for the conversation
  • Content that was discussed (include specifics)
  • Action items for all parties in the conversation (what are you going to do next? what is the other person going to do?)
  • Next planned contact (either a date and time, or after a specific event occurs)

Make a log entry for every conversation, no matter how short or insignificant it may seem at the time. You never know when you might need that tiny piece of information.

A health care notebook allowed me the peace of mind of having my mother's health information at my fingertips at all times, without requiring me to remember every detail on my own. I can't imagine going through a health care crisis without one. For your sake and the sake of your loved ones, please consider creating one.

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    • Marcy Goodfleisch profile image

      Marcy Goodfleisch 5 years ago from Planet Earth

      These are great ideas to help caregivers track what is happening, or as a way for someone with a complicated health problem to keep everything straight. I know from the years I spent as a clinic administrator that our physicians and other practitioners would have appreciated having access to some of the records you've mentioned, too.

      Voted up, and up again!