Careful record keeping is important to inform your role as your child’s critical advocate in hospital.
Keep track of all procedures, treatment and how your child responds, so you can be the best possible advocate
When you keep records neatly organized, you will be able to monitor care and will not be reliant on the hospital or doctor’s office to send information for you. This will reduce delays and stress.
In a large ring binder, use divider tabs to create the following sections.
- Contact details (doctors, social workers, child life, insurance etc)
- Medical reports (EUA, office exams etc)
- Results (lab reports, scans, etc)
- Treatment plan (protocol, regimen etc)
- Medications (drugs, doses, schedules, allergies etc)
- Daily diary (record appointments, procedures and summarise discussions)
- Notes (use this to write questions and take notes during consultations)
- Official documents (child’s birth certificate, insurance cards etc)
- Finances (all insurance correspondence, billing and other information)
Collect business cards from all treating physicians, social workers, child life and other important contacts at the hospital. This will come in handy when seeing a new physician, or if you need a quick reference – particularly in an emergency.
Some stationers sell business card pocket sheets for ring binders. Alternatively, photocopy the cards onto one master sheet and add it to the front of the folder.
Place all test results, medical reports and documents in the folder as soon as you receive them. Do not give originals to anyone else and do not remove them from the folder unless absolutely necessary – make copies and pass on the copy.
Make copies of everything. Include several copies in the folder with the original document. Do not hand over your originals or your only copy from the folder.
This applies to personal documents as well, such as birth certificate and insurance cards. They may get lost or you may forget who you gave them to.
Ask for a copy of films from MRI, CT etc, in addition to the report. These are often provided on a CD loaded with the software required to open them. This makes the files difficult to copy on a regular computer.
Ask for several copies of the CD so you will always have one if you need to send a copy to another doctor for a second opinion.
If you send off your only copy, replace it in the folder with a note of the named person you sent it to, and their contact details. Only send films and CDs with a signed-for delivery service.
Remember you are your child’s advocate. Check that the nurse scans your child’s name band before giving any medication. Ask for the name and dose of each medication. Don’t be intimidated, but be respectful.
Nurses are human and occasionally make mistakes. Most mistakes relate to drug administration, and you can help prevent errors by being vigilant.
Record all prescribed drugs in the medications section of your folder so you can cross reference if you are unsure. Include name, start/stop dates, dose and frequency for each.