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How to Keep a Medical Journal

I'm an expert scrapbooker, which makes me great at keeping medical records.

Keeping health records is critical for tracking your progress or changing symptoms.

Keeping health records is critical for tracking your progress or changing symptoms.

How To Keep Your Own Medical Records And Why

If you have a chronic disease and see multiple doctors, it's really important not to assume that all your doctors are communicating information to each other. You are responsible or should be a partner in your medical care. So what should your responsibilities be? What can you or your caregiver do to make sure that each of the physicians in your life has the most amount of information to help you navigate your health issues? Here are some suggestions for you to consider to make it easier to navigate around different medical offices and clinics.

Three-ring binders are the perfect way to keep your medical records. You can adjust the binder to your specific needs with dividers. You can color-code your binders to delineate individuals in your home. Pages and reports are easy to add.

How Can I Acquire Medical Records I Don't Currently Have?

By law, you have the right to copies of all your medical records. That being said, facilities have the right to charge a fee for making those copies. If you are unable to go get your reports and information, most facilities will honor a request by you to give a caregiver that information, if you put it in writing and date and sign the request. Either you or your caregiver will need to show a photo ID in order to get that information

Why Should I Keep My Medical Records?

Another reason to keep a medical journal is that if you need to apply for long-term disability or social security disability, you need documentation to prove your case. Having all the information at your fingertips makes it easier to navigate the system.

How I Got Started Keeping My Medical Journal

A few years ago I was diagnosed with an autoimmune disease in my liver. In addition to my general practice doctor, I wound up with a gastroenterologist. Then I added a surgeon specialist for about a year. I dropped him and wound up with a hepatologist. Then, after some additional issues, I added a rheumatologist. Then there is the cardiologist that I see once a year. One doctor I see every three months, the regular doctor as needed, and the rheumatologist I have seen twice. Most times one or the other orders blood work, x-rays, or ultrasounds. I can't always guarantee that each of my doctors gets the reports that the other one orders. So, I started keeping a loose-leaf book with all my information. That way, all of my doctors get all the information.

What To Keep In Your Medical Journal

Your medical journal should be very personalized to your needs, but there are a few things that it should have common to everyone.

  • Your personal information: phone, address, name of spouse, next of kin
  • Your insurance carriers: Both primary and secondary carriers
  • Name of pharmacy where you get your meds: Phone number, meds, and fax number
  • Names, phone numbers, and faxes of all your physicians: I like to grab one of their cards and place it on this page. That way if one doctor has to relay information to another, you have that information at your fingertips
  • The names and doses of all your medications, including any over-the-counter medication: That would include all of your over-the-counter vitamins and supplements. Every time you have an appointment with any of your doctors they will ask you for an update. If for some reason you have to go to an emergency room, that information will be available. Include the name and phone of your pharmacy.
  • History of all your surgeries and procedures: This is especially useful when you are seeing a new physician.
  • Any condition or diagnosis: What have you been diagnosed with? List the condition or disease and when.
  • Any allergies to medications or otherwise.
  • Blood work results. In my case, I go to multiple doctors and it's important for each of them to be on the same page with all my results, so I keep copies of my blood work available when I go to my doctors. One word of caution on this one: Be careful not to read too far into the results of your blood work. Instead, have your physician go over the results with you and explain to you the meaning of them. They are the ones best to define what is important and what is not.
  • Any radiology reports: It's important to have that information in case your physician wants to know the last time that you had a particular test. If you have received copies of X-rays, cat scans, or sonograms, keep them also. Another facility may want them to compare.
  • Any pathology reports
  • Any other tests: EKGs and other tests
  • Your family history: It's important for any of your physicians to know what kind of diseases or histories your family had.
  • Immunizations or shots: You should include any immunizations that you have had, or any shots like the flu shot, pneumonia shot, etc.
  • Hospitalizations: Include dates and location and why you were admitted
  • Dentist appointments: Dates, treatments, Xrays

Your Job Is to Be Truthful

This information is for you and your physician. Your doctor will make a diagnosis, and order tests and medications based on the information that you give and his examination. It is critical to your care to be totally honest in the information that you give him. Being a partner in your health care means that you and your doctor have a relationship of honesty and trust.

Your Symptoms: How Are You Feeling?

It's important, especially when you have a chronic condition or illness, to advise your doctor about your current symptoms. He/she is not a mind reader and omitting that information may cause the doctor to consider a different treatment plan. Let them know the main things that you are feeling, especially if what you are feeling has changed or gotten worse

Keep diligent track of your records so you know what works and what doesn't.

Keep diligent track of your records so you know what works and what doesn't.

Write Your Questions Down

Have you ever left a doctors appointment and realized that you have forgotten to ask him a specific question? I know that I have. Write down your questions so that you will remember what you wanted to address with him. It makes life so much easier.

How To Set Up A Journal/Medical Binder

Free Printable Medical Journal Forms

How I Keep My Medical Journal

I keep my medical information in a loose-leaf binder. I have made sections that work for me. I keep one year's worth of reports. I have my medical history, medications. family history, and other records altogether. It's very simple to create a binder with the sections that apply to your situation. After the year ends, I place that year's tests and reports in a folder on my desk for future reference.

Some people keep their medical journals separate from their binders. I prefer to keep it all in one location.

Caregivers Should Keep A Medical Journal

What if you are a caregiver to a spouse, a parent, a child, or some other adult in your family? If you have been given this trust then it is really important that you have access to all the health information that will help you make decisions and guide the person that you are caring for in order to help them or make medical decisions for them if the case comes to that point. A medical journal is a tool that will help you navigate through the system.

Try to have a conversation with the person you are caring for so that you know how they feel about end-of-life decisions. Make sure that you understand, if possible, what their wishes are with regard to medical decisions. You will also need to know if they have documents like a living will or a do not code order. Know who the health care surrogate is if you are not the person named. The health care surrogate is the person who is named to make medical decisions if the person is unable to speak for themselves. Get a copy of these documents and keep them in the journal of the person you are helping. Never assume that the hospital or health care facility has these on record.

Make sure that you are with the person you are caring for whenever they see their doctor if possible. Ask them to give the physicians involved in their care permission to speak to you on their behalf.

Having the medical journal for those you are caregivers to will help you navigate the medical system easily. It will help you care for those you love and make it a less stressful situation.

Patient Portals

More and more physicians are turning to patient portals as a tool to communicate with patients. They also contain some information as the physician provides access to whatever they ant to use the tool for. Some will allow you to make appointments and request medication refills. Some will allow you to ask a question through an email. Others will show you test and lab results. They will also show statistical information about you. Some will also show clinical information from your visits. It's important to spend some time understanding and learning to use the patient portal that your doctor provides.

Medical Journals Are Important When Filing For Disability

If you have a chronic illness that becomes debilitating, medical journals will help you document the reasons that you are unable to work. Charting your progression with your illness as well as how your illness has effected your ability to work will be helpful information if and when you have to apply for disability

This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2015 Linda F Correa


Linda F Correa (author) from Spring Hill Florida on April 14, 2015:

It's a wonderful idea for any caregivers, especially at a time when a caregiver may have to give information when they can't or are unable to answer questions that are important to care

Donna Herron from USA on April 13, 2015:

Thanks for this wonderful advice. My in-laws are beginning to have serious medical issues and my husband and I are having to catch up on a lot of the information you list. Thanks for this great starter on the info we need to start collecting.

Linda F Correa (author) from Spring Hill Florida on April 04, 2015:

Anyone with an acute or chronic problem should keep a medical journal. It is essential to keeping track of multiple doctors and events

Linda F Correa (author) from Spring Hill Florida on March 31, 2015:

That's why I suggest that anyone dealing with a chronic or acute medical condition or anyone who is a caregiver takes this step. It is important to be proactive in your health care

Missy from The Midwest on March 31, 2015:

I wish I had read this when my Post Concussion Syndrome was at its worst. I used to struggle to remember whether I took my meds, and I completely blanked out when my doctors asked about my symptoms. To this day, I still can't remember the name or location of one of my doctors, so I can't go back to see him. Good tips.

Linda F Correa (author) from Spring Hill Florida on March 20, 2015:

All the best to your Mom. I know how challenging being a caregiver is. Now you have given me lots to add to this article about how caregivers can benefit from this information too. Thanks for your prospective

FlourishAnyway from USA on March 19, 2015:

Excellent information! This is very useful advice, especially as people grow older. You never know when you'll have to hand over care to a care partner, even temporarily. For example, my mother is seeing many doctors right now for a whole host of medical issues and 4 scheduled surgeries this year. She cannot see well at all (one of her medical issues -- affects both eyes). It would have been nice to have this all in one place rather than via her verbal recollection or scattered papers. Voted up and more and sharing. I wish you well in your health issues.