At Home DIY Everyday Gear Medical Practice

Make A Medical Record Book, Part 2 – How to Use It

In a previous post, I described the components of the medical notebooks I use for my dad and family. The notebook comes along on every medical appointment, and this is how I use it.

Before each appointment, I fill out a form I made on my computer and printed up in advance. It’s my Medical Appointment Record form, which goes in Section 2. I’ve typed in cues on the page (date, doctor’s name, current symptoms, any questions or concerns). Before we go, I fill in the blanks. This ensures that we have a clear idea of what we want to know and that we’re organized and able to use the appointment time effectively.

In Section 3 I keep printed lists of current medications, with the patient’s name, the title (Current Medications) and the date in bold letters. Each medication is listed, followed by the date it was first prescribed, the strength, the dose frequency, and the diagnosis or the purpose of the medication.

I type any known medical allergies in bold, capital letters in bright red across the top of the Current Medications page. ‘Obvious’ is good where there’s potential danger.

I print two copies of the Current Medications page before each appointment — one for the notebook, which stays in Section 3, and one for the doctor’s office, which gets put into Section 2, right after the Medical Appointment Record form. Vitamins and any dietary supplements also go on this page, along with any consistently used OTC (over-the-counter) products like antacids, arthritis rubs, etc.

If we’re seeing a new doctor, a copy of the personal Medical History and one of the Family Health History also go into Section 2, so it’s easy to turn over the copies at the appointment.

Before each appointment, I put copies of any test results that are relevant to that day’s appointment into Section 4. Any test results that haven’t been discussed yet, or about which there are questions, get moved from either Section 4 (Current Test Results) or Section 8 (Other Info) into the clear pocket in the front of the binder so they can be referred to easily when talking with medical personnel.

Once we’re at the office, and as soon as we get in to the examining room, I write down the name of the nurse or assistant and his or her title on the Medical Appointment Record sheet, and make clear notes as advice is dispensed. I also record weight, blood pressure, and pulse on this page, as each is taken.

After each appointment, I review any new information, update any new medication information and make any new additions to the personal medical history so that the record book is ready to go next time it’s needed.


Making a Medical Record Book, Part 1 — Putting It Together

Making a Medical Record Book, Part 3 — Tips and Tricks

2 replies on “Make A Medical Record Book, Part 2 – How to Use It”

This is an excellent idea. I am going to start suggesting this to our patients. I am very impressed with your blog and the information you have on it. Please continue because i think there is a lack of good senior and disability related websites out there. thanks.

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