Tips on keeping medical notes and records organized

August 5, 2008 3:12 PM

I'm looking for tips on organizing personal medical records and information, assuming a chronic or complicated health problem. Things like X-rays and MRI discs, blood test results, prescriptions, notes taken during appointments with the doctor, notes made on non-appointment days about symptoms, medical history, insurance policies and bills, therapies tried and discontinued... what are great ways to keep it all organized, for ease of use (and consistent record-keeping) both for the patient and his care partners?
posted by xo to Health & Fitness (3 answers total)

We have a real simple system. A plastic basket on my desk. Everything medically related goes into the basket. At the end of the year everything goes into a large folder labeled with the year, and it's filed. I figure we'll always be able to remember what year something happened, and we don't go back to it often enough to justify a lot of time creating a complicated filing system.

We haven't lost anything important yet, and we have a chronic condition in the house that generates lots of prescriptions, tests, etc.
posted by COD at 4:15 PM on August 5, 2008

I'm not an expert on medical records, but I used to do a lot of taxonomy in my previous job and I see you only have one answer so far, so...

I think a good thing to do would be to think of the top three scenarios in which you imagine using the information. For example: in case of emergency? When meeting a new doctor for the first time? Convincing a new doctor that what seems like 12 years of unrelated symptoms really adds up to lyme disease? Knowing how you want to use the info will help figure out how to organize it. Off the bat I can see a few ways: chronologically, as COD suggests; by ailment--everything related to your severe migraines, for example; or by type of data (all MRIs together, all x-rays together, etc.). Pick the one that best meets your top three scenarios. Then, you'll probably need to add another level or organization (all MRIs, by year -or- all MRIs by ailment). Then label all the non-paper-based materials in a way that reflects this hierarchy.

I think you should digitize as much as possible (all the notes for example) and tag them with key words. That will really help slice through things in the event that the data isn't organized in the particular way to meet, say, a scenario #8.

Personally, I just keep a running word document for my 3yo. Every 6-12 months he has a checkup and I bring this doc. It's organized like so:
- At the top of the doc is emergency information (blood type, current weight for dosing purposes, allergies, current medications, family history of diseases, etc.)
- Next is dates and reasons for previous hospitalizations/surgeries or chronic conditions.
- Next is any concerns I've noted over the last six months (ex: his hearing) or questions I want to ask (when should kids first go to the dentist) and a list of any minor illnesses since his last checkup (a fever with rash type XYZ)
- If I'm bringing him in because he's sick, I make a note of symptoms, onset, location, what makes it better, what makes it worse, etc.

For your purposes, you could add a section that accommodates follow-up: medications and therapies prescribed & acted on, tests run and results, and outcomes.

This way, all the critical information and current concerns are at the top, and a history of previous concerns keeps getting pushed lower, but still in the same document. You could also annotate entries with "See MRI disc #2008_August_DrHighmark" to remind you that other media is available.
posted by cocoagirl at 7:07 PM on August 5, 2008

I've kept paper records chronologically in a binder, so it's a time-based history, much like the way I've seen doctor's charts ordered. I feel like it makes sense because it puts the events in context ("we tried dosage X after event Y, and added Z in 3 days later when X was not effective")

My mom is a dietitian at a nursing home, and I recall the records from the different departments written on different colored papers, then inserted into the chart/binder chronologically. So, having, say, food/diet notes on light blue sheets, oral advice/notes from the doc on yellow paper, etc, can also help keep it together.

However, for quick reference, you can also keep additional individual spreadsheets for other common categories. These might include a separate quick reference spreadsheet in the back for each of the specific categories: medications, shots/immunizations, physical therapy log, etc.

If this is a common combination of chronic conditions, perhaps you can ask advice from the doctors, patient advocate at the hospital, or a support group, if any of those apply.

And, this might be personal preference, but I like the confidentiality/non-crashability of paper.
however I'm sure there are software based tools (Google Health is a particularly [interesting]/[frightening] one considering how much [google rocks]/[google has so much info on us already]) (depends on your perspective!)
posted by NikitaNikita at 7:14 PM on August 5, 2008