Records & Case Management
MRN: About the Medical Records Notebook (MRN)
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This notebook has been designed to help you through the medical process you have ahead of you. The less you have to keep in your head, the more time your family will have to spend loving each other. Medical crises put a lot of strain on relationships, but they also give wonderful opportunities to see just how much you mean to one another. Allow others help you as much as they can, especially in the areas of every day living such as shopping, meals, errands, etc. It will leave you free to do the things only you can do. For instance, refer friends to the instructions for this notebook on the website and let them put it together for you.
As the mother of children with serious medical conditions, I have experienced first-hand the difficulty of organizing critical medical information while in crisis. It is my hope that The Medical Records Notebook will assist you in this task.
You will need the following to set up the Medical Records Notebook
- 2” 3-ring binder
- 3-hole-punched pocket folder
- Set of 8-tab dividers
- Notebook paper
- Forms listed below (Forms are provided on this site)
To set up the notebook, make a section for:
- Insurance Information
- Take a copy of your insurance card (front and back) on its own sheet of paper and put it first in this notebook. You will be asked the number numerous times. Facilities prefer the original document, but if you don’t have your wallet, etc., this can do in a pinch. Make sure it’s a good copy. If possible, enlarge the print so that the small print can be easily read including phone numbers for emergency, admitting authorization, etc.
- Appointments
- Note every time you see or call a physician or therapist.
- Medical Notes
- This will become one of the most important sections of your book. From ICU through post-rehabilitation, take notes each time you see a doctor or therapist—whether in the hospital or a routine doctor’s office visit. When overwhelmed, it’s hard to remember everything you’re told. This process will allow you to peruse important information at a later time.
- Medications
- Use this section to complete two charts. ALWAYS take both charts with you when you go to the emergency room. The medications you are taking will effect what the medical staff can do for you.
- Medication List
- A complete list of all medications (prescription and non-prescription) being taken.
- Medication Chart
- Weekly - A weekly chart that you can “x” off as you take your meds. Whenever a medication is taken for the first time, be alert for any reactions. It may be helpful to buy a book on prescription drugs such as the Physician’s Desk Reference Guide and read yourself about any possible drug interactions. If you are given something that shows up on the "interaction" list, speak up.
- Consent Forms
- You will be asked to sign a consent form for every procedure done on you in a hospital or doctor’s office. Keep all consent forms. They are your verification in case there are problems. Being able to present what you've agreed to may also save you a trip to the admitting office.
- General Information
- Use notebook paper and a pocket folder to keep all information you receive on your medical condition – research, new medications, newspaper articles, doctor referrals from other people, etc. It’s a good place to keep business cards also. This file becomes helpful down the road if you have to explore new options.
- Addresses & Misc.
- Using notebook paper, write down the address and phone numbers of friends and family you may need to call in case of emergency. Use other pages to note any miscellaneous information.
- Kindness Shown
- In times of need, you discover the giving nature of the people around you. This chart will help you track what others have done for you and your family and give you a place to note your response.
Other types of Medical Records that need to be tracked include:
- Admission history and physical summary
- Medical/Rehabilitation Evaluations
- Neuropsychological Evaluations
- Primary treating physician’s discharge summary
- Operative notes
Because the hospital records listed above can be large, it may be more feasible to keep them in separate files rather than in The Medical Records Notebook.
Sharon Brookshire has worked extensively in third world countries as a missionary, directing humanitarian efforts to improve the quality of life for children. She developed The Medical Records Notebook to track information for two of her children who have long-term medical conditions. Sharon now manages a nurse’s registry in southern California.