As a caregiver, you have a lot of responsibilities. There are doctor’s appointments to schedule and attend, medications to administer, and endless duties around the home to keep your loved one safe. It can be easy to get overwhelmed and misplace documents or forget infrequent obligations. In this article, we hope to simplify one of those infrequent and often tedious, (but hugely important) obligations: keeping track of medical information. We’ll explore why you should keep medical information, what information you should keep, and how to organize it in a way that is simple and easy to maintain over time.
Why keep documents?
There are many reasons to keep medical records, and we’ll explore a few of those now.
- Giving doctors the most up-to-date information. You may run into a situation that causes an unexpected urgent care or emergency room visit or need a second opinion with a new doctor. In this situation, having your loved one’s medical records is crucial.
- Keeping track of changes. Over time, blood work, for example, may start to show a pattern that a single test result couldn’t detect. Keeping records may help you find it.
- Double-checking information. From time to time, doctors or pharmacists may make mistakes. Having a record of prescriptions or immunizations, for example, may help if you notice issues.
What documents should you keep?
This list is not exhaustive but is meant to be a guide. (Source.) These are some of the most useful documents to keep organized and bring with you on visits to any medical facility.
- Laboratory Results. Lab results include both blood and urine test results. It’s useful to keep at least the last few years of results together in one file.
- Cardiac Tests. These include treadmill tests, EKGs, tests for coronary artery disease, etc. These tests are useful for a team of doctors trying to make prescription decisions or to diagnose something related to a heart or lung problem.
- Radiology Results. CAT scans, MRIs, ultrasounds, etc. are all useful test results to store. They may prevent duplicate tests from being ordered and provide more context to the doctor.
- Pathology Reports. If your loved one has had a biopsy, the results are useful to doctors who may inspect the same issue or related symptoms in the future.
- Hospital Discharge Summaries. These summaries are really useful to future medical teams as they are written by professionals for professionals. This is not the same document that is handed to you as you leave – this is a document you would need to request. But it contains very detailed information about any chronic issues as well as the reason for and results of the hospital stint.
- Advanced Directives. Any advanced directives that have been put together should be kept on file with all medical information. In the event of an emergency, these clear any confusion over your patient’s wishes.
- Medications and Prescriptions. Keeping an up to date list of medications and prescriptions your loved one is taking is crucial (it may be the most critical on the list).
How should you store these documents?
You may have access to a patient portal through your loved one’s primary care physician that details their medical records, immunizations, allergies, test results, and more. This is a useful tool, but we still recommend keeping your own copy of these documents as well for a couple of reasons. First, your personal health record provided by a doctor is limited to the information that that single doctor/office has. By combining records you’ll be able to create a full picture. Second, in the event you switch providers or wind up in the hospital, these records are easily accessed and are under your control.
Let’s talk about how to store them. You’ll want something that keeps the information safe and accessible (or printable) in the event you need it on short notice.
- A binder or accordion file. This is a classic file storage and organization technique, but it works. Keeping a separate tab for each type of document and having it all printed and organized is a great way to ensure you have exactly what you need when you need it.
- A digital file (like cloud or USB drive storage). This storage technique will allow you to share documents with other members of the family and can easily be backed up, which means you always have a copy (in the event of a fire, flood, or something else that could damage physical property). It is worth noting that storing files this way can be difficult to do well – keep file names consistent and dated to ensure you can find what you need when you need it.
- Use an Assistive Technology. There are many online software services that have been created to help with these problems and more (Microsoft has developed a free health filing system you can use by clicking here). It may be time-consuming to set up and maintain, but systems like this keep your documents encrypted and safe from disaster.
Maintaining records in a way that is easy to update, safe to store, and quick to grab and share is a crucial role for caregivers. We hope this article was helpful to you in planning how and why you should store medical information.
The role of caregiver is always tough, but you’re part of a large, strong, and helpful community of people including and beyond your family who have been in your shoes. The California Caregiver Resource Centers were created with you both in mind and at heart to be a free resource as you navigate the challenging role you’re in. We would love to connect you with your local Center, which can talk more about local programs and support groups for caregivers, answer your questions, and explain how they can best support youShare this post: