Arthritis Foundation | Caregiving Advice | Organizing Medical Records

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It’s critical to set up a method of organization to keep track of the many responsibilities of a caregiver. Simple solutions are sometimes the best.

Keep a current calendar and refer to it several times a day.
Keep a current to-do list; revise it before going to bed and read over it first thing in the morning.
Create a notebook to keep the patient’s medical history and pertinent information in one location. This notebook should be clearly marked, kept handy at all times, and contain enough information so that someone filling in for you will know exactly what is needed and how to do it.

For those who prefer a product specifically designed for organizing and storing medical records, several are available:

A Health Organizer can be found in the Juvenile Arthritis Alliance store.
A Personal Health Record (PHR) is a confidential, easy-to-use tool to manage information about health records electronically.
Or you can purchase a health journal at your local bookstore.

If you prefer to organize a more personalized, detailed notebook of your own, suggestions for notebook divisions and content follow.

Section 1: General Information

Patient’s name
Address
Telephone number
Birth date
Social Security number
Family doctor’s name and phone number
Name of health insurance company, member number, and phone number
Medicare and/or Medicaid number
Pharmacy name and phone number
Emergency contact name and phone number
Nearest hospital name and phone number
A map showing the location of doctor and hospital.
Blood type
Allergies to drugs, foods, bees, etc
Special conditions (having diabetes, epilepsy, a pacemaker, etc)
Information about a living will or health care proxy

Section 2: Providers

The next section should contain all providers, their specialties, their phone numbers, and the medical condition that they’re treating. Include home-care providers, acupuncturists, massage therapists, chiropractors, and anyone else involved in the patient’s care.

Primary care physician/geriatrician
Heart specialist
Orthopedist (specializes in bone, joint, and muscle problems)
Endocrinologist (specializes in diseases of the glands)
Cancer specialist
Foot and hand specialist
Eye doctor
Ear, nose, throat specialist
Dentist
Allergist
Neurologist
Psychiatrist
Psychologist, counselor, or social worker
Physical therapist
Nutritionist or dietitian
Visiting nurse
Home care aide

Section 3: Medications

List all prescribed medications, the reason they were prescribed, and the doctors who prescribed them. Identify the start date and dosage, along with where the medications are filled and stored. Record any vitamins, herbs, supplements, and over-the-counter medicines taken regularly.

To make this task easier, AARP offers a form for recording personal medications online.

This section of the notebook should also provide resources for additional drug-safety information, such as new drug warnings, drug label changes, shortages of medically-necessary drug products, and recall alerts. Two good resources are:

FDA Drug Safety and AARP’s Drug Directory. You can also visit AARP or call 1-888-OUR-AARP (1-888-687-2277).

For more thorough information about medicines, see our section on Managing Medication.

Section 4: Health Conditions

In this section, include all health conditions (arthritis, osteoporosis, high blood pressure, etc). Also list hospitalizations, dates, durations, reasons for the stay, and outcomes.

Section 5: Exams, Tests, and Screenings

Record dates and results of all examinations, tests, and screenings here, including regular physicals with height, weight, and blood pressure. After each entry, list when the test needs to be re-administered. Make certain your loved one is screened for the following conditions:

Cancer
Diabetes
Osteoporosis
Cholesterol
Eye and vision problems
Dental problems

Section 6: Shots

List vaccination dates (flu, pneumonia, tetanus, tuberculosis, allergy, etc).

Section 7: Family Medical History

As much as possible, include a medical history of extended family by writing the names and relationship of family members who have had cancer, heart disease, dementia, mental health problems, diabetes, and other conditions. Include the relative’s age when he/she had the condition, if known. If deceased, record the cause of death.

Section 8: Questions for the Doctor

Jot down questions to ask the doctor, pharmacist, and other health care providers. If there’s an ongoing list of questions, your concerns won’t likely be forgotten at the next visit.

For more information, see our sections on Working with Health Professionals and Talking with the Doctor.

Section 9: Care Routines

Schedule, steps, and necessary items for care or treatment routines. Don’t forget to list where any needed items are stored.