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Personal Information: Biographical information such as name, birth date, place of birth, social security number, address, etc., should be included. Also include educational history, preferences in food, likes and dislikes or any other information of a personal nature. A list of immediate family members, contact information, and relationship to each may also be included. Emergency Information: Emergency contact information for the primary contact, along with the preferred backup, if the primary emergency contact is unavailable, should be readily available. It is important to make sure the emergency contacts are aware of their responsibilities if an emergency occurs. They should be aware of the existence of the healthcare and other information and have access to it. If there is a medical power of attorney, a living will or other legal documents that may be needed during an emergency, copies of these documents should be easy to access. The persons likely to handle an emergency in the absence of the primary caregiver must know where the original notarized documents are stored in case they are needed. Healthcare Providers: Records should include information on all medical personnel involved in the care of the individual. Keeping the information for each provider is important in order to establishing treatment history. Information should include dates of visits in order to create a historical record of treatment. New providers can be added as they become involved. Physician Clinic Notes: It is important to keep copies Doctors notes and reports for all visits to any physician regardless of the reason. Most Physicians will supply copies of the notes when requested. A written and signed request for a copy of the notes should be presented at the time of the visit. Medication History: Developing a log sheet to track medication history can avoid complications at a later date. If there are allergic reactions or other issues such as behavior changes, etc., these should be documented. History and Physical: Hospital admit and discharge notes that describe the injury, assessment and treatments as well as discharge plans can be important in seeking medical attention or appropriate residential placement. These records should include reports for all hospitals, rehabilitation and other treatment facilities and should include each hospitalization, no matter what the reason. Insurance/Financial: Information on insurance and other financial information can be important to securing services. Copies of insurance information (workers compensation ect), Social Security card, Medicare or Medicaid card, military discharge papers, VA benefits card or any other applicable entitlement information are best kept together and accessible to those who may need to act as a caregiver. If a card or document is two sided it is important that the copy is of both sides. Community Information: Information on any community programs and/or agencies associated with the individual can be important to document. These may include Area Mental Health, Social Services, vocational programs, support groups or others. Include information on the name of the contact for each agency and the role of that the agency or group. Making frequent updates insures that the contacts are accurate. Personal History Notes: A diary of personal information can be useful to document events and situations that affect the individual. It may also be used as a tool to communicate with other caregivers when the care giving is a shared role. Information can be reviewed before doctor visits in order to address any noted concerns. While each caregiver must develop his/her own method of tracking and storing information, it is important to keep it simple. Records should be kept in such a way that anyone who may need to draw from the information can locate the facts they need with minimal effort. Good record keeping can insure appropriate and speedy treatment in emergencies and avoid mistakes that could have a negative impact on the person with the injury.
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