Parental Medical Record

While it is true that you can get copies of your child’s medical records from doctor’s offices and hospitals, you may find them disappointing. The information is often too large to be useful.

In our many years of taking care of children with special needs, we have often been impressed by the 3-ring binders which many parents make for their children. We would encourage all parents of children with special needs to consider keeping one for their child. Don’t be afraid to ask your doctor to ‘cc’ you on their office notes–it doesn’t do any good for the doctor to have a plan if you don’t know what it is!

Here is a run-down of what you might want to have in your child’s book:

1. Problem list (or a list of all diagnoses)
2. A complete History and Physical (H&P) from one of your doctors (preferably type-written)
3. Medication list (keep on a USB drive for easy editing) and include:
   1. Name of medication(s)
   2. Strength of medication (and concentrations of liquids, i.e. 5mg/5mL)
   3. Amount given
   4. Route (by mouth, G-tube, J-tube, other)
   5. Frequency (5x per day) or times given
4. Allergies to medications
5. Allergy to latex (if present)
6. Feeding regiment
   1. Formula type
   2. Calories per ounce (if mixed from powder)
   3. Bolus amount and rate (given over 15 minutes, etc.)
   4. Feeding schedule (4x per day or 8am, 12am, 4pm, 8pm, etc.)
   5. Continuous feeding rate and hours given (example: night drip, 10pm to 6am at 55mL per hour)
7. A list of all doctors (some people put their business cards in a plastic business card holder)
8. Growth chart
9. Maps to the lab (Labcorp, SonoraQuest, etc.)
10. Maps to the doctor’s offices
11. Discharge instructions from hospitalizations
12. Metric conversions
13. 3-ring Pencil case with:
    1. Foley (in case G-tube can’t be put back in)
    2. 5 mL syringe
    3. Insurance card
    4. Immunization record
    5. Child’s Social Security number

Sample Pages In a Medical Record Notebook: