Medical Record for In Home Care

Keeping a medical record is an important part of in home patient care during a pandemic. Accurate information will help your doctor make good decisions, especially if consultations need to be made by phone. Here is a contact form so that you can easily keep track of contact information for people you may need to reach.

Keep a patient record in a notebook.
Photo courtesy of Jeremy Mikkola

During a full scale flu pandemic , medical care may be stretched thin. Not only will hospitals run out of beds, but your family doctor may also be run ragged, trying to keep up with his case load of sick patients. You may be forced to consult with your physician by phone.

Another alternative that might work for you is to use doctors online advice . You will be able to ask a legitimate doctor a question and get a personalized answer, usually within minutes. Keep it in mind--just in case you need it.

Before you call your doctor, make sure that you are organized and prepared. Doctors who are overwhelmed will expect your discussion to be short and sweet.

You must be ready to give your physician the medical information—in a summary. Know what you will say when you talk with the doctor, and be ready to answer any questions that your doctor may ask.

Medical Chart - What You Should Record

Keep your patient record notebook outside the sick room , near the phone. That accomplishes two things. First, you won't spend unnecessary time in the sick room, exposing yourself to the virus. Second, if the doctor's office calls, you will have your patient's medical record near the phone.

Every time you make an entry in your patient's medical record, first record the date and the time. This will help both you and the doctor see the progress of your patient, and help you to keep things straight. Don't rely on your memory! Here are the things you need to record:

• Symptoms - What do you notice? Skin color, sweating, coughing, vomiting, etc. What did your patient tell you? Record that as well. Do the symptoms seem more severe ?

• Medications - Record any flu medicines that you gave to your patient in his medical record. How much did you give your patient?

• Blood pressure - This is easiest if you have a digital blood pressure monitor.

• Temperature - If you have little slip-on plastic covers, discard them after each use. Otherwise, wash the thermometer with soap and water and then sterilize it with rubbing alcohol. A digital thermometer is the easiest to use, and it takes very little time to get the patient's temperature.
  
  

  

  Photo courtesy of Victoria
  
  

• Pulse - If you have a digital blood pressure monitor, it will give you the pulse rate. If you don't know how to take a pulse rate, simply record that it seemed “fast” or “slow”, based on what you think it is.

• Respiration - This is a little tricky if you haven't done it before. Respiration is the breathing rate. It will be helpful to the doctor if you record that your patient was “breathing fast”, “breathing slowly”, “having trouble breathing”, “sounded like mucous when he breathed”, etc.

• Liquid in - With a high fever, it is important to make sure that your patient doesn't become dehydrated. Record the amount of liquid that she drinks. With a really sick patient, don't worry about solid food. But make sure your patient does get enough liquids.

• Liquid out - It will be important for the doctor to know if your patient is peeing. I'm not recommending that you measure liquids like a nurse would. Simply record that your patient used the bathroom (or didn't). If you have an idea about quantity, record that, as well. For example, “a couple drops”, “normal amount”.

• Patient comments - What did your patient tell you? Record anything that you think is significant. Record comments that indicate that the patient is feeling better, or worse.

That's all there is to it! Keeping a medical record for your patient is not difficult. Just be organized, and every time you check on your patient, record what you did, record what your patient said, and record what you observed.

If you have a question for a physician, you can get a personal answer quickly at doctors online advice.

Return to Flu Treatment

Flu Treatment for Specific Symptoms

Anitviral Drugs for Pregnant Women

Natural Flu Remedies for Pregnant Women

Hospital Care

Cytokine Storm

Pandemic Flu Guide HOME - from Keeping a Medical Record