No more drowning in piles of paper. It’s time for New Year’s resolutions and a great time to think about getting your child’s health records organized. Have you ever misplaced an important number? Left the doctor’s office and remembered something you wanted to tell the doctor AFTER you left? Did your child’s IEP go missing right before a big meeting?
Organized records help you review the history of your child’s care, appeal an insurance decision and provide a resource for answering the teachers’ and doctors’ questions. Most importantly, organized records are easier to access in case of an emergency.
You are your child’s first health care provider. In order to completely participate in decision-making for your child, being organized is necessary for your New Year’s resolution list.
Choosing a System
In choosing a record keeping method, figure out what works best for you. Start by collecting paperwork in one box and working on it a little at a time. Each child should have his or her own separate set of records.
Some families prefer electronic methods of record maintenance, while some prefer notebooks and others binders. For some, a combination might work. Whatever system you choose, think about maintaining notes for any of the following:
- telephone calls and discussions
- important papers
- contact and insurance information
- questions for the doctor
- medical and immunization history
- allergies and medications with dosages
- IEPs and evaluations
- school work samples
- home-school communication
- information on medical equipment
- therapy notes
Before choosing a method of record maintenance, consider your child’s needs. For some families, it will be difficult to separate educational and medical records. For children with behavior disorders or mental health issues, there will be a lot of overlap in the records you’ll need for doctors and educators. For others, two separate systems might be needed.
Organizational Systems for Records and Documents
You might try using the downloadable Medical Diary from Bayou Land Families Helping Families. The medical diary has information sections for all sorts of information, including school information. You can use it all or print out just forms you’d like to use for your own version.
Wrightslaw, an advocacy organization for special education, suggests that papers be kept in chronological order in binders separated by tabbed sheets that are numbered and indexed. This is a good method of document maintenance. But not everyone will be able to maintain it, especially if you do not have a computer to type indexes. If you do choose this method, be sure to create a shortcut for the index on your computer. This will make searching for a document faster. I don’t recommend keeping children’s work samples in this same book. It makes it difficult to get a handle on your child’s progress when work samples aren’t together. Do keep work samples in chronological order though so you can get a true picture of progress. One difficulty with this method is that if your child has complicated medical problems as well as educational issues, the system can be burdensome and difficult to use when visiting the doctor.
In that case, consider a separate notebook, binder or electronic thumb drive for information the doctor will need. The Medical Diary referenced above includes forms you can use to document a wide variety of medical information as well as tips for questions to ask the doctor at various stages of your child’s care. Or, take a look at the American Academy of Pediatrics Care Notebook.
Think about including home-school communications in both records if you maintain two separate systems. Information the school provides on behavior or medical needs could be important to your child’s doctor(s) or in applying for things like Medicaid waiver programs. Consider scanning copies of the communication daily or weekly or making copies on an inexpensive home copier for your paper files. When scanning, be sure to name your documents and save them in an organized way so that you can easily retrieve them. File them by school year in folders on the computer.
Organizational Systems for Telephone Calls and Other Communications
Keeping track of telephone discussions can be easy when you use a telephone call log. There are forms available for hand writing or typing in your information on the computer. One such form is available in the Medical Diary at the link above. You can also make a running telephone log by using tables on your computer and entering in a row for each phone call.
When using forms, make sure you have one form for each call. Don’t combine them as it will be confusing. File them by the particular issue you are trying to solve with the calls, or in the case of general communication with a doctor or teacher, file chronologically. Be sure to include on the form, the date, time and length of the call and who you spoke to. Include whatever promises and deadlines were made on the call. Attach documentation so you have it for follow up calls. If you use the computer for this instead of a form, simply make a folder on your computer for all the typed forms and save a shortcut to your desktop so you can access it quickly.
Or, for a more portable way to document calls and appointments, you could use a student planner. Be sure to get one with not only the month-at-a-glance page, but pages behind that to enter notes for each date. When you have a discussion with a professional, note it on the full calendar (“Telephone Call to/from Dr. Jones”) and then behind that page in the section for that day, write notes of what was said. Highlight deadlines, promised materials, and other important information. Enter dates of behavior problems, mental health issues, dates of all other doctor appointments and lab tests that were taken or are scheduled that the doctor may need to be aware of.
Organizational Systems for Contact Information, Equipment, and Appointments
Keeping track of contact information can be difficult if you aren’t organized. The Medical Diary referenced above has forms you can use to record insurance and provider contact information. Consider purchasing a few business card sheets that are made for binders and include those in with your child’s records so you can easily find provider business cards. Remember to record phone numbers on any handwritten telephone call logs you create as well so you can refer back to them.
If your child has a lot of medical equipment you’ll want to keep track of it, including the dates supplies have been received and expire, supplier names and contact information, maintenance needed and contacts for repairs, as well as where loaner or temporary equipment should be returned. Use either the forms you find at one of the links below or start your own on your home computer.
Before any meeting with doctors or educators, consider what questions you want to communicate with them. You may find that a spiral notebook with pockets works well for you. Write them in your notebook and note at the top the date/time and reason for the meeting or appointment. Leave room for yourself to write down the doctor’s or teacher’s answers so that you can refer back to them later. Let them know that you are maintaining a record for your child to help you better partner with them for your child’s future health and education.
What to Keep and Archive
Generally, it’s not a good idea to get rid of medical records since you just never know when you might need them again. But, if you can scan them in for backup, that’s great. Consider putting all important information on a portable thumb drive with folders for each member of the family. Put a copy with emergency evacuation information. Back up what’s on your computer to the thumb drive every three months or so and keep it with you in case of an emergency. When storing your medical records, never box up documents without inventorying them. Keep copies of the indexes of each binder and indexes of the box on your computer for easy review.
Number and log in the boxes so you know where to find items when or if you need them. Keep important school records with data that’s collected by the school system, including copies of the daily notes that come home regarding behavior or school performance. This information can be very important in talking with your doctor about issues your child is having.