Keeping and organizing medical records

Why should you keep copies of your child’s medical records?

Keeping copies of your child’s medical records is an important part of your role as your child’s advocate. Here are some reasons for keeping these records:

1. You can take time to review the records for accuracy.

2. You will gain more detailed knowledge about your child’s condition. This will help you feel morecomfortable when you talk to your child’s doctors.

3. You will have a resource to answer questions about your child’s condition.

4. You will have the records on hand during emergencies. Emergency departments may not have easyaccess to your child’s records. You should bring the most current and relevant records with you if yourchild needs an emergency room visit.

5. If your child sees several specialists, you can collect all your child’s records in a comprehensive set foreasy access.

6. You will have records available if you file an appeal for health coverage or apply for a public program.

Suggestions for organizing medical records:

Keeping track of your child’s medical records can be overwhelming. Once you create a recordkeeping system,organizing the records should become easier. Here are some suggestions:

1. Use a three-ring binder divided into relevant sections. (See below.)

2. Purchase a commercial medical record organizing system.

3. Keep all records in a box until you have the time and energy to organize them into a three-ring binder.

This way you will still have the information, even if you don’t have the opportunity to organize it.

Organizing a three-ring binder system:

Every child has a unique set of records. Your binder will not necessarily contain all of the sections listed below. However, you can use this list as a guide to help you get started.

1. Addresses/phone numbers: List contact information for your child’s primary care physician,

specialists, and pharmacist.

2. Medications/immunizations: Keep a chart of medication and immunization information that details thedates given, any side-effects, medication changes, and the reasons for the changes.

3. Lab/test results: Keep track of the type of tests taken, dates performed, the location, reference norms,and results.

4. Doctor visits: Keep a list of the date, the doctor visited, symptoms, diagnosis, and the outcome of thevisit.

5. Medical history: Detail your child’s diagnoses, any specialized plan for handling illness, surgeries, past hospitalizations, growth and development information, adaptive equipment used, and other past health information pertinent to your child.

6. Home health care: Keep a chart of telephone records with home care agencies and copies of service plans.

7. Therapies: Keep information about therapies that your child receives, including the type, provider names, and dates.

8. School information: Keep a list of contact people within the school system, a record of phone calls, and education records, including IEPs, report cards, and notes from meetings.

9. Advocacy records: Keep a record of phone calls made to advocacy organizations.

10. Financial/insurance information: Keep a record of phone calls to insurance companies, a copy of your benefit plan, insurance claims, bills, and payments made. If you have a significant amount of insurance records you may want to create a separate binder to collect and organize this information.

11. Phone record: Keep a list of phone calls made to health care providers and other persons involved in the care of your child. The list should indicate who you spoke with, the date, reason, and follow-up information.

Keep your own notes

Notes about your child’s condition. Keep detailed notes about your child’s condition when you notice unusual changes. The information that you record will depend on your child’s situation. You may want to record factors such as: temperature, eating patterns, sleeping patterns, and reactions to medication. Be sure to record exact times of the events you note. This information is important for the doctor to consider and more useful than a general description.

Notes about calls to the doctor’s office. You may consider keeping a spiral notebook by your telephone to keep a log of phone calls to your doctor’s office. In addition to writing down what was discussed, record the date and time of the call along with the name and title of the person that you spoke with. This way you will have detailed information available for follow-up calls.

from PACER