Personal Medical Journal
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- Jocelin Rodgers
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1 Personal Medical Journal PersonalMedJournal_es.indd 1 12/13/2010 4:25:41 PM
2 Table of Contents Personal Medical Journal Information... 3 Background Information... 4 Clinical Care Ready To Go Home Medical Terms Notes PersonalMedJournal_es.indd 2 12/13/2010 4:25:41 PM
3 Personal Medical Journal The personal medical journal was designed to help you keep track of your past and present medical care. You are encouraged to write in the journal and bring it to appointments. You can even bring it during a hospital stay. Share your journal with your doctors, nurses and healthcare team. Using your journal can help keep you involved, informed and invested in your healthcare. As you track your medical history, remember that you play a key role on the healthcare team. You will work closely with your healthcare team for the best results. Listen carefully and use open and honest communication. If you don t understand something, don t be afraid to ask questions. This Personal Medical Journal Belongs to Name: Home Mobile Emergency Contact Information (In Case of Emergency) Name: Relationship to Patient: Home Mobile 3 PersonalMedJournal_es.indd 3 12/13/2010 4:25:41 PM
4 Personal Medical Journal Primary Care Provider Name: Address: Important Contact Information of Family and Friends Name: Relationship: Insurance Provider: Name: Address: Name: Relationship: ID#: Name: Pharmacy Information: Name: Relationship: Address: 4 PersonalMedJournal_es.indd 4 12/13/2010 4:25:41 PM
5 Background Information Other Important Contacts Include contact information for your hospital, specialty providers and patient advocate. An advocate is someone you can trust to look after your welfare and help you ask important questions. Name: Specialty: Address: Name: Specialty: Address: Name: Specialty: Address: 5 PersonalMedJournal_es.indd 5 12/13/2010 4:25:41 PM
6 Personal Medical Journal Vaccinations NAME DATE LAST RECEIVED Allergies Food allergies, medication allergies and other allergies. ALLERGY REACTION SEVERITY OF REACTION (mild, moderate, or severe) Is the allergy life threatening? 6 PersonalMedJournal_es.indd 6 12/13/2010 4:25:41 PM
7 Background Information Medications Include: prescription medications, non-prescription medications, over-the-counter medications, herbals and supplements. NAME OF MEDICINE DOSE (amount) HOW OFTEN AND WHEN? (morning, noon, evening) HOW TO TAKE (with or without food) REASON FOR TAKING 7 PersonalMedJournal_es.indd 7 12/13/2010 4:25:41 PM
8 Personal Medical Journal Medical History Past medical surgeries, injuries and hospitalizations TYPE OF SURGERY, INJURY, REASON FOR HOSPITALIZATION DATE 8 PersonalMedJournal_es.indd 8 12/13/2010 4:25:41 PM
9 Background Information Current Conditions High blood pressure, asthma, etc. CONDITION DATE DIAGNOSED Advance Directives Legal documents that state your preferences about medical care. Do you have an advance directive? Yes Share a copy with your healthcare team. My advance directive is located: No If you are not familiar with advance directives or would like further information, talk to your doctor or healthcare team. 9 PersonalMedJournal_es.indd 9 12/13/2010 4:25:42 PM
10 Personal Medical Journal Daily Hospital Diary For use while you are in the hospital to record the following: DATE: Your healthcare team (doctor, nurse, therapist) All medications you received Procedures/Treatments/Tests Pain or Discomfort (0 to 10 scale 0 for no pain 10 for worst possible pain) Questions Notes 10 PersonalMedJournal_es.indd 10 12/13/2010 4:25:42 PM
11 Clinical Care Daily Hospital Diary DATE: Your healthcare team (doctor, nurse, therapist) All medications you received Procedures/Treatments/Tests Pain or Discomfort (0 to 10 scale 0 for no pain 10 for worst possible pain) Questions Notes 11 PersonalMedJournal_es.indd 11 12/13/2010 4:25:42 PM
12 Personal Medical Journal Daily Hospital Diary DATE: Your healthcare team (doctor, nurse, therapist) All medications you received Procedures/Treatments/Tests Pain or Discomfort (0 to 10 scale 0 for no pain 10 for worst possible pain) Questions Notes 12 PersonalMedJournal_es.indd 12 12/13/2010 4:25:42 PM
13 Clinical Care Daily Hospital Diary DATE: Your healthcare team (doctor, nurse, therapist) All medications you received Procedures/Treatments/Tests Pain or Discomfort (0 to 10 scale 0 for no pain 10 for worst possible pain) Questions Notes 13 PersonalMedJournal_es.indd 13 12/13/2010 4:25:42 PM
14 Personal Medical Journal Daily Hospital Diary DATE: Your healthcare team (doctor, nurse, therapist) All medications you received Procedures/Treatments/Tests Pain or Discomfort (0 to 10 scale 0 for no pain 10 for worst possible pain) Questions Notes 14 PersonalMedJournal_es.indd 14 12/13/2010 4:25:42 PM
15 Clinical Care Daily Hospital Diary DATE: Your healthcare team (doctor, nurse, therapist) All medications you received Procedures/Treatments/Tests Pain or Discomfort (0 to 10 scale 0 for no pain 10 for worst possible pain) Questions Notes 15 PersonalMedJournal_es.indd 15 12/13/2010 4:25:42 PM
16 Personal Medical Journal Clinical Care Daily Hospital Diary DATE: Your healthcare team (doctor, nurse, therapist) All medications you received Procedures/Treatments/Tests Pain or Discomfort (0 to 10 scale 0 for no pain 10 for worst possible pain) Questions Notes 16 PersonalMedJournal_es.indd 16 12/13/2010 4:25:42 PM
17 Ready To Go Home Current Conditions DATE: The following section is helpful after you have had a test, procedure, surgery or hospital stay. It will help coordinate information about your condition, medications and follow-up appointments. Diagnosis (condition) Have you reviewed your discharge instructions with your healthcare team? Yes No Do you understand what you need to do when you leave the hospital? Yes No Medications Medications you need to start or continue when you go home. NAME OF MEDICINE DOSE (amount) HOW OFTEN AND WHEN? (morning, afternoon, evening) HOW TO TAKE (with or without food) REASON FOR TAKING FOR HOW LONG 17 PersonalMedJournal_es.indd 17 12/13/2010 4:25:42 PM
18 Personal Medical Journal Home Health Care If you need help after you are discharged from the hospital, your provider will order home health services. This is when a nurse or member of the healthcare team comes to your home to provide medical care. Name of Company: Contact Person: Date: Reason for Visit: Name of Company: Contact Person: Date: Reason for Visit: Name of Company: Contact Person: Date: Reason for Visit: 18 PersonalMedJournal_es.indd 18 12/13/2010 4:25:43 PM
19 Ready To Go Home Follow-up Appointments Date & Time: Location: Reason: Remember to Bring (e.g. my medical journal): Questions: Date & Time: Location: Reason: Remember to Bring (e.g. current medication list): Questions: Date & Time: Location: Reason: Remember to Bring (e.g. current test results): Questions: 19 PersonalMedJournal_es.indd 19 12/13/2010 4:25:43 PM
20 Personal Medical Journal Ready To Go Home Follow-up on Lab & Test Results TEST DATE Activity Recommendations Nutrition/Diet 20 PersonalMedJournal_es.indd 20 12/13/2010 4:25:43 PM
21 Medical Terms Medical Terms You May Hear in the Hospital or at the Doctor s Office Diagnosis: naming of a disease or illness, also known as a condition Discharge: when your doctor decides you are healthy enough to leave the hospital Discharge Planning: planning that takes place before you leave the hospital Follow-up Visits: doctor s office visits that you schedule and go to after leaving the hospital Healthcare Provider: a person, like a doctor or a nurse, who provides healthcare Healthcare Team: a team of medical persons, like a doctor, nurse or therapist, who provide care for the mind, body and spirit Home Health Care: care you receive from a doctor, nurse or therapist in your home after leaving the hospital In-Patient: a person who is admitted to the hospital Length of Stay: the number of days that a patient remains in the hospital Medication Management: knowing which medication(s) you need to take at what time, and why you need to take them Medication Reconciliation: the process of comparing which medications you are taking at home to what you are given at the time of admission or entry into a new healthcare setting or level of care Patient/Discharge Advocate: a person who assists you in resolving any issues with your care and informing you about your healthcare choices Patient Safety: a new healthcare discipline that stresses the importance of the reporting, analysis and prevention of medical error Primary Care Provider: a healthcare provider who plans all of your care when you leave the hospital Readmission: when a patient returns to the hospital within 30 days of their original discharge date 21 PersonalMedJournal_es.indd 21 12/13/2010 4:25:43 PM
22 Notes 22 PersonalMedJournal_es.indd 22 12/13/2010 4:25:43 PM
23 Personal Medical Journal Notes Notes 23 PersonalMedJournal_es.indd 23 12/13/2010 4:25:43 PM
24 268 Summer St. 6th Floor Boston, MA Fax: National Patient Safety Foundation PersonalMedJournal_es.indd 24 12/13/2010 4:25:43 PM
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