Inside the American Medical System: Making a Medical Notebook I (Part 5 in the Series)

After our appointment with our baby's first specialist - when we received a mistaken clinical diagnosis of Downs Syndrome - both DH and I reacted in very personality-specific ways. In other words, DH got on the phone (and stayed on for the next six months), and I started making computerized forms and compiling a medical notebook.

I ended up being the one in charge of medical records, appointments, and all communications, and having a medical notebook was a life-saver. Until you've been there, it's hard to imagine the complexity involved in coordinating and connecting multiple people (doctors, nurses, secretaries) in multiple offices, in multiple hospitals and locations, and making sure that each office is in communication with the others and that each has all of the records and lab results needed. Without sufficient organization, it can turn into a nightmare.

In this section, I will share the two main forms that were our lifeline, and then (in the next part) some additional minor forms. Unfortunately these are not printables (I have yet to figure out how to make printables - enlighten me, someone!), but you are welcome to copy and paste for your own use.

Two Major Forms

(1) Phone/Fax Email Record

As soon as our adventure began, so also began the phone calls and emails (and faxes and letters).

All. the. time.

It was constant. And keeping track of them - in exact and minute detail - was vital, because I had to have every single bit of information at my fingertips and ready to give to other caregivers. The key to being in the medical system successfully is having all information at the ready at all times. Thus, when we began, I used the following form every time that I was on the phone (calling or being called) or that I received or sent any other communication. I cannot tell you how helpful this was, and it was vitally useful almost every day.

When issues come up - and they do, often - one of the most helpful things is being able to pull out a sheet of paper and say, "I talked with Maria at 8:17 a.m. on Monday, January 20th, 2014, and she said such-and-such." When you have chapter and verse, people take you seriously.

Phone/Fax/Email Record Date:                                        Time:                             □ Received a call Person Receiving Call:                                                     Person Telephoning:                                                                  Office/Practice:                                                                   Return Number:                                                               □ Made a call Person Telephoning:                                                           Person Receiving Call:                                                               Office/Practice:                                                                   Return Number:                                                       □ Sent fax / email           To:                                                                                               Fax # / Email address:                                                      □ Received fax / email           From:                                                                                           Fax # / Email address:                                                      Record of Call/Fax/Email:

* A side note: I used a similar method of record-keeping when a local OB practice kicked me out of their office after finding out that I had hired a midwife. Although it took me nearly a year to get around to writing to the head OB about my experience, when I did so, I was able to quote details down to exact dates, times to the minute, physician and secretary names, locations, conversation details - everything. That, combined with a calm and reasonable tone, resulted in an incredibly positive interaction with the head OB. He didn't change his mind on dealing with midwife clients (though I hope that a seed was planted), but our interaction was great. When you can stay calm and stay organized, great things happen.


(2) Doctor Visit Record

A second sheet was the following - a record sheet for each doctor visit. I would complete the first part while we were in the waiting room, and the second part right after our visit. It was incredibly helpful to have detailed and accurate records. Sometimes I could just hand my notebook over to a specialist for him or her to go through my records of other doctor visits, and each of them loved it!

(It also really impresses doctors to see clients who are intensely organized and detail-oriented - and that's always a great way to start a doctor-client relationship off on the right foot!)

Having records of payments and addresses was also helpful for tax purposes. (I actually kept different record sheets for taxes, but I won't go into that here.)

Doctor Visit Record Patient:                                                                                            Date and Time:                                                                               Specialist type:                                                                                Doctor:                                                                                            Practice:                                                                                          Address:                                                                                         Phone:                                                                                            Fax:                                                                                                Reason for visit:                                                                              Payment:                                                                                        Advice, Prescriptions and Other Notes:

In the next part, I will share some additional minor forms that we used to keep records in our medical notebook!

Click on Part 6 to keep reading!