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Your Health Care Chart Format!

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Format for Personal Health Chart

by Siri-Gian Khalsa




This is a great way to keep medical information complete and updated for doctors’ review, especially when there is a lot of information!  Doctors have very little time in your appointment to understand what is going on with their patient.  So, this is a quick summary with back up material—test results, etc.


This is written for the care giver, but you can make and use your own!  Start now so that you will have records for the future!


I developed this when I was taking care of my parents—especially for my mom who had extremely complicated medical challenges and treatment.  This is how I kept it all straight and got the best out of the medical people that I took her to.




Before going to see a medical professional, write out a list of symptoms, observations, and history of the “complaint” so that they won’t have to try to draw it out of you, and you forget things.  This way, you can get started early, put in on your computer to update it as you think of new things, and by all means put the dates of everything in—including treatments and when new symptoms arose.  Be as organized as you can with this material.  Include the patient’s name, the date of the appointment, who this paper was written by and your telephone number.


When you go to a doctor’s or other professional’s office, be sure to take a notebook and pen and write down exactly what they said.  Ask questions—by all means, and even repeat back to the professional what you understand and ask them if that is right.  Do your research and be really, really prepared!


Do not ever be a victim.  Always try to be patient in your temperament and to understand what is being said or done.  Ask about ideas you may have for treatment.  And you’re your input.  Even if things are going screwy, do your best to be calm and hold your center.  If you need to, you can be really, really firm.  Only scream when you have to because no one will listen to you any other way. 


Don’t be insulting—no matter how difficult things get.  That’s how you lose allies—whether that be the person you are insulting or telling off, or others in earshot, or even those who hear the gossip and so don’t want to go near you.  Be professional yourself, and hold your own.  Do your best to see that things are going right, and respect your person in the decision making process if it is appropriate—small children and demented adults can’t participate in decision making very much. 


Care Management is an extremely tricky business, especially because you are feeling the stress of caring for someone you love in the best way, but don’t have the medical expertise.  But just do your best, and do your meditation and exercise, and eat and rest well to ease the stress!




The first section is about the patient, and this is the information that you keep in your computer and update every time you get more information.  The first time that you see a particular doctor, therapist, etc., give them a printed out copy of the whole chart that you have put together.  Then subsequently, each time you visit a doctor that you have already seen, you give him/her copies of any updated material that they need—usually the first section on their diseases or conditions, but take the whole book with you to the doctor’s office, just in case they need to see more.  The receptionists are always good about making copies for the doctor if need be.  Don’t give up your own copies of reports—give extra copies.  More on how to construct this booklet is on the following pages under “THE HEALTH CHART BOOK.”




The second part contains copies of the reports—blood, CT scan, etc.  Use your tab dividers to note the name of a certain condition, disease, or body system that is being investigated, such as “Lungs, Heart, Depression, Parkinsons,” etc.  And keep one section for “Blood,” because those are ongoing.  Then put your reports under that appropriate category, always putting the latest one on top.


Often times the testing facility will not give these reports to you.  So, find out how you can get them.  Sometimes when registering for the test, you can ask that a copy of a report be sent to you as well as to the doctor, and sometimes they will insist that you get the copy of the report from your doctor.  It is essential that you follow up with this and stay on top of it.  YOU ARE THE ONLY ONE WHO WILL BE HOLDING ALL OF THE PATIENT’S REPORTS!  If you go to a number of different doctors, the reports may be spread out among those doctors and no one gets a comprehensive view.  So, you should have a COMPLETE record.  Often times, doctors still use FAX machines to send copies of reports.  Some doctors may be upgrading to computer now, although they may use computers to send them for privacy reasons.  So, if you are getting lots of reports, it might be good to get a FAX machine.  Check out what your doctors use first, though.


If tests or courses of care were done in the hospital, hospitals seem to not want to share any information if they can help it.  So, if you need to, go to their records office and request either the reports from specific tests on certain days—you have to tell them the tests and the days, so keep track, or you can request the full record of everyday’s occurrences, along with the test reports.  You may have to wait a month to get these, depending on the hospital’s policy.


If the patient had anesthesia, ask for the anesthesia report as well.  It will include a graph, and note if the patient did well or not, and what any specific problems were.  Then if your person has to have another surgery, the next anesthesiologist can tell what worked or didn’t work for your person.


Be sure to check out the films (x-rays, CT scans, MRIs, etc.) or get copies so the originals can stay with the facility, as they usually say they require.  You may have to pay for any of these.  And with the current privacy laws, you will probably need identification to take them.  And if you are picking these up for another adult, you may need their signature with their direction to release these things to you.  So, carry this book that you are making with you when picking up records and reports.  You should put copies of all your legal papers such as your power of attorney; or if this is for a child—their birth certificate, and custody papers, if any.




Every set of films comes with a report, so be sure to get that report with the films—somehow!


I find it really beneficial to keep all the films from all the x-rays, radiological scans (CT and MRI), etc.  That’s because they often come from a variety of sources that is difficult to keep track of, especially when they are in other cities.  Also, it is not uncommon for those facilities to loose films once in a while.  So, either get copies or the original films.  If they ask you where you are taking them, just give them the name of your internist, but keep them yourself.  And if you ever need to leave any films with a doctor for their review, get a receipt from their office with a notation on when you will be picking them up!  Doctors’ offices also loose things.


Also, some facilities are keeping their film records on computers now, but you may need their software to receive and open them.  So, find some way that you can keep these pictures or copies of them in your file.


Get yourself a portfolio from an art store that is about 24” long to keep the large envelopes of films in, and keep the films grouped by body part, e.g. head, chest/lungs, abdomen, full body, etc.  And stay on top of keeping these films organized and in your possession—both new ones and ones that you have lent out.  Store them in a cool, dry, safe place—very important!  Then when you see a doctor about something that already has films taken of it, be sure to take the films with you to the appointment.  And then take them home and put them back in the portfolio.  Very important! 


I actually used two portfolios—one for storing all the films, and another just for transporting the films to the doctor.




Get yourself a good short book on anatomy and physiology (how things work).  I like “Atlas of the Human Body” by Takeo Takahashi, HarperPerennial, 1989.


Also you can get a good, concise medical dictionary such as Dorland’s or Stedman’s and you can also get a medical dictionary online from “Medline Plus: Medical Dictionary.”  You can google any of these.


Then if your patient is going to be receiving drugs, I recommend a good, professional drug resource such as any one of several books meant for nurses, e.g. “Nursing 2008 Drug Handbook, Springhouse, Springhouse, PA.  Also any of the PDR (Physician’s Desk Reference, Thomson, Montvale, NJ) are good.  The whole line of PDRs cover those for doctors, nurses, mental health professionals, herbal medicines, nutritional supplements and so on.  They have a website, I’m sure. 


Also, some good books for courses of medical treatment are:  “Current Medical Treatment and Diagnosis,” McGraw Hill, that doctors use.  Also “Merk Manual of Medical Information, Home Edition,” Pocket Books Health, NY is good.


And for herbal and nutritional supplement information, I like to use “Prescriptions for Nutritional Healing,” by Balch and Balch, Avery-PenguinPutman, NY at your health food store.  Check the PDR for Herbal Medicines to determine if your herbs interact with your prescription medicines.  You can even take this reference book to your doctor when he/she is prescribing drugs if you are taking herbs.  “PDR” is a name they trust.


You can also look up tons of stuff on Medline.  Google it.  This is a site put up by the US National Institutes of Health Medical Library and gives you “abstracts,” which are short synopses for research articles published in the huge number of medical journals.





Get yourself a medium size 3 ring binder, lots of page dividers with tabs, and a 3 hole punch.  And I assume that you already have a computer—totally important to write and keep your documents.  Keep the records that you create as a file on your computer and print out the pages as you need them.


In the front of this book, put in copies of the front and back of your patient’s insurance cards, social security card, and driver’s license or other photo ID.  If they are too young to have a photo ID, copy a recent and recognizable photo of them.


In the back of your book under the tab “Legal”, you can include copies of your legal and notarized Power of Attorney, and/or Medical Power of Attorney, and Living Will.  Of if this is a child, put in a copy of their birth certificate, and custody papers if pertinent.  In this case, as the custodian, also include your (the custodian’s) photo ID as well.


Content:  These sections will be listed in order.



This is what you hand the doctor every time you go.  It is a quick look at the whole patient, which is quite difficult, and maybe impossible for anyone doctor to gather.  List these:


  • “Information as of – (this is the last date you updated any information in this part of the chart)”
  • Patient’s full legal name, nickname, and birth date

This is a short introductory paragraph that tells how old the patient is, what sex they are, what their interests, activities or other life conditions currently are, where they live, description of their living situation, who their support people are, what the patients habits are, what their mental and physical conditions are, what their current challenges are, and any other short but pertinent information.

  • A number of short paragraphs that describe the patients conditions grouped under each disease, condition, body area, or system that are especially pertinent to the patient—such as: Skeletal System (e.g. broken bones, osteoporosis), Immune System—(e.g. AIDS, parasites, frequent colds and flu), Psychological---(e.g. depression, bi-polar disorder), Brain—(e.g. learning disorder, encephalitis), Lungs (e.g. frequent pneumonia, smoking damage), and so on.  These descriptions don’t have to exactly follow this format, but they should give all pertinent information very, very succinctly!  And list these category paragraphs alphabetically.


How to record information under each of these categories:

    • Head each paragraph with the System, Disease, Body Area, or Condition that will be addressed.
    • For each disease or condition, etc.: name the condition, date or year it was diagnosed (abbreviation for diagnosis is Dx), current condition including symptoms, e.g. “vision continues to worsen, and cannot read regular print even with glasses,” or “shortness of breath” or “well-controlled,” how it is controlled—abbreviation for prescriptions is Rx, and that can include doctor prescribed drugs (not dosages), therapies, surgery.  Include use of non-prescription remedies, but don’t use “Rx”.  And, if necessary, a brief history (abbreviation is Hx), such as “increasing pain in liver area for 5 years before diagnosis.”  History may include a short list of what was tried but discontinued along with the dates.


    • If the condition or disease and its progress are best described by a succession of test results—such as the spread or healing of cancer, you can create a table that compares test results over time under that section.


You can get pertinent information from the tests to get the wording to explain these technical things to doctors.  But don’t go so technical that they suspect you of Munchausen’s syndrome!


Here are a couple of samples of these descriptive paragraphs.


Hypo-Thyroid—Originally hyperthyroid, Grave’s Disease Dx 8/01.  10/17/02 radiated thyroid, especially to treat goiter and exopthalmic condition, however eyelids and eye pouches are still drooping and fluid filled in hot weather (which may be a side-effect of Hydrocortisone taken for Addison’s disease).  Exopthalmia appears to increase.  Hypothyroid treated with Levoxyl.


LungsBreast CA metasitasis Dx 3/12/04 in right posterior hilar area, and right lung base posteriorly.  Hospitalized for pneumonia 4/17-29/04, 13 days Levaquin IV.  Oxygen and nebulizer treatments in hospital also helped O2 saturation level.  7/6/04 discontinued home O2 equipment; Pulmonologist Dx no COPD, good lung function, some infiltrate in right lower lobe, left lung clear.







Basic Personal Information.

Patient’s legal name, nickname and birth date:

Patient’s social security number:

Patient’s address and phone numbers:

Health Insurance Providers, their insurance numbers and group numbers, their effective dates (the date you started), and what employer is providing this plan.

The primary caregiver’s name, relationship and all phone numbers

If you are divorced from your child’s parent, note that.

Additional caregiver’s names, relationships and phone numbers


If your patient is 18 years or over, make a note on this paper regarding whether the patient has a Medical Directive or Living Will, and/or a Medical or general Power of Attorney, and who are the patient’s agents in that case.  Then include copies of these documents in this booklet under the “legal” section.


If your patient is under 18 years, include birth certificate and any documents that indicate court ordered custody and include that as well.  Mark that on this sheet, too.


Family History—as of the date you last updated this.

(These family members are blood relatives that could share similar genetic heritage.  These are definitely father, mother, brothers and sisters, children and grandparents.  You can include some aunts, uncles or cousins if they share any of the conditions in your patient.)

List: Relationship, age or age at death—important health problems.



 Mother: living, 42 years old, depression, alcoholism, gastric ulcer

Father:  living, 45 years old, high blood pressure, glaucoma



Immunizations—list them in order of date given


Oct. 21, 2005, Flu Shot

Oct. 28, 2006, Flu Shot

July 15, 2007, Tetanus Shot



Non-Hospitalized Conditions—(these are the ones for which the patient got emergency medical treatment, or which were fairly serious but perhaps of short duration.  They did not stay in the hospital for treatment.  Put these in chronological order, with date, problem and remediation, place of treatment.)



2/4/03—flu-like nausea and diarrhea causing dehydration.  Received 2 litres rehydration at Fairfax Access.

10/17/02—Radiated thyroid to reduce goiter and also swollen eyelids due to exopthalmic condition.  Dr. Powers

2/20/01—Fall on new right knee replacement.  OK, Sibley Hospital, emergency room.



Hospitalizations and Courses of Care—(these are the times that your patient actually stayed overnight and received care or observation for a condition, or received out-patient treatment from that hospital as a result of being hospitalized there, such as outpatient rehab.  List these episodes chronologically, include dates and treatment.  If my person goes to a variety of hospitals in more than one state, I like to keep these episodes grouped accordingly.  It is easier for the hospitals to look up old records that way.  You may want to include a brief summary of why the patient sought out that hospital.)



Johns Hopkins, Baltimore, MD; Need for corrective spine surgery as a result of failed spine surgery originally done June 11, 1996 in VA.  The failure caused danger to spinal cord, chronic pain and lumbar kyphosis.  (Collapsed L2 and L3 graft with failed instrumentation.)

Nov. 30, 1998, Dr. Kost, Replaced L2-L3 with graft and instrumentation from T12-L4.

Dec. 1-16, 1998 surgical ICU, very low blood pressure and fluid exchange difficulty, 70 lbs. of edema, (ischemia to organs, 2 episodes of atrial fibrillation, necrotic bowel, hemotoma of tongue (great swelling and necrosis), tracheotomy 12/14/98, trach removed 1/8/99.

Dec. 5 & 8, Dr. Nake, removed colon and gall bladder, ileostomy.




NEW PAGE:  (Since there are a number of these “NEW PAGES”), you can decide how you want to break up these page categories, according to how much information you have to put into them.)


Doctors and Services:  Start with the patient’s legal name, and “as of (last date this list was updated.”)

These are the hospitals, testing facilities, therapists, equipment suppliers, etc.  I like to group them according to states or similar locations if need be.  Then put the preferred hospital first, and the preferred testing facility second on this list.

Then list the doctors and services by their specialties in alphabetical order, with the primary doctor underlined.  Include their phone number and their FAX number.  And keep them on the list until you are sure that you never want to use them again.



In Virginia:

INOVA FAIRFAX HOSPITAL: Patient number 03352515: 703-698-1110

FAIRFAX RADIOLOGY:  Woodburn Office, 8-5, M-F:  703-849-9050

Cardiologist: Dr. Frank Hortini, 703-698-8525, FAX 703-882-9133

Endocrinologist:  Dr. Peter Roster, 703-870-3200, FAX 703-859-3201

Internist:  Dr. Rona King, 703-821-0383, FAX 703-821-9028




Medical Services and Testing:  Sometimes a facility will have phone numbers for several different departments that you need, or a company that does testing may have several different locations.  List each by their head—either the facility or the testing company, and then add the phone numbers for each.



Inova Fairfax Hospital, 3300 Gallows Rd., Falls Church, VA 22042

            Main: 703-698-1110;  Patient Room 703-698-2+patient’s room number.

Medical Records:  703-698-3307, FAX 703-204-6456, Matika

Fairfax Radiology, 3299 Woodburn Rd. ste. 110, Annandale, VE 22003, M-F 8-5.

            Woodburn Office: 703-849-9050, FAX orders 703-698-4491

            Scheduling: 703-698-4488

Central Film Library:  8305 Arlington Blvd., ste. LL100, Fairfax, VA 22031, M-F  8:30-5, 703-698-6882, FAX 703-698-7944.






 If your patient has had any replacement parts put in, such as joint replacements, pace maker, eye lenses to replace cataracts, etc., this is where you list that information.  You may have to dig for it, but in the future you may find that it was really necessary!  For instance, this pacemaker company has recalled some of their leads.


And if you order supplies regularly, list them with contact information, and the full catalog description of what you need so that you don’t have to search for it every time.



PACE MAKER: Dr. DelNegro 707-849-0770 (This is the surgeon who inserted it.)

Original pacemaker Sept. 1992. Replacement 1/10/00.

Replacement Pacemaker:  Manufacturer: Guidant Corp., 1-800-227-3422;

 Model # 1270; SN: 6043521

A-Lead Manufacturer: Medtronic; Model # 4086M; SN LAW 34825V (not replaced).

V-Lead Manufacturer:  Guidant: Model # 4054; SN 403561 (not replaced).


OSTOMY SUPPLIES:  Edgepark 800-321-0591

1810 Summit Commerce Park, Twinsburg, OH 44807

Ostomy Pouch:  Holister, #3668, drainable pouch with karaya 5 and filter, 1 ” stoma

Eakin Cohesive Seal: Small seals, 1 7/8” diameter

Hollister Universal Remover Wipes

Hollister Skin Gel Protective Dressing Wipes





MEDICATIONS as of (the last date you updated this list)

Patient’s legal name.


This page is organized in three main sections.  They are:

  • Medications he/she is now taking:
  • Supplements or herbs he/she is now taking:
  • As needed:  (These are medications and supplements that are not regularly scheduled, but are taken in case of special needs, such as occasional pain or nausea when they come up.)


Each of these sections is arranged into the same three columns.



MEDICATIONS SHE IS NOW TAKING                                                 DATE STARTED

Levoxyl           0.112 mg. 1xday, before breakfast—replace radiated thyroid          12/7/02

Remeron         2 tabs. of 30 mg.= 60 mg., 1x day, bedtime—for depression                       1/17/03

Florinef Acetate 0.1 mg. 1xday, breakfast, reduce high potassium                          2/13/04



Vitamin B6     50 mg., 1xday, breakfast—for depression                                         12/1/03

Olive Leaf Extract 1 cap. of 500 mg., 4xday—prevent UTI                                     8/27/03


As Needed:

Zofran             8 mg.—for nausea                                                                              6/22/04

Nitroglycerin  0.3 mg. (1/200 gr.) dissolve under tongue for chest pain or faintness 5/2/05




This is a kind of catch all page that has lots of little bits of necessary information.  It can include the names of your pharmacies, your durable medical equipment provider, home care services, etc.  Be sure to include their phone numbers, their hours of operation, your contact person, and address if necessary.  With this, your doctor can easily phone in an Rx.




CVS, Falls Church, 703-534-4500; Yorktown 24 hour 703-560-7280

Medco, Mail-order, 800-262-8134.




The medical people regard Allergies to medications differently than Side-Effects.  To them, an allergy is known to produce a very great negative effect in your person, even life threatening that your patient has gotten from taking a particular medication—such as they can’t breathe, seizures, extreme nausea and vomiting, hallucinations, etc. 


Side-effects of a medication are still nasty and should be kept track of so that your patient doesn’t have to have that same experience with that medication again.  List these in alphabetical order.





Dilaudid tablet or IV—nausea and vomiting

Zinacef (antibiotic)—burning hives, nausea



Antibiotics—yeast infections, cystitis, although for surgery Ancef IV is preferable

Neurontin—sleepy, dopey

Prevacid—nausea, feels bad


Now these following categories of medications are especially good when needed. Please make up your own according to your patient.



Breakthrough pain—Oxycodone or Oxy IR, 5-10 mg. PRN up to 4 x day.  (PRN means when the patient asks for it.)

Anesthesia—Fentanyl (no side effects, good for pain relief)



Compazine tablets—5-10 mg. PRN up to 3 x day (10 mg. and over can cause great sleepiness)

Zofran IV—is the most effective in severe cases.





Discontinued Medications:  (When the patient goes off a medication or the dosage changes, take it off the sheet that says that they are currently taking this medication and paste it onto the top of this list, so that you will always have the most recently discontinued medications at the top of this list.  And with this list, you can always refer back to see if your patient has ever taken that med.  And if it is not on the allergies or side-effects page, you can assume that they didn’t have a bad reaction to it.  Also, the doctor can see what dosages were used.  Add the date this med was discontinued to the date it was started so you know the time span of the usage.)


Use the same three columns as you used for the medications that your patient is currently taking.



Tylenol, Rx                 1-2 tablets as needed for pain.                                   3/24 to 5/18/05

Acular Eye Drops       0.5%, 1 drop in each eye, 1 to 4 x day           3/21-4/8/04





List of supplements and medications that your patient takes at specific times of day.  This is especially important if you are in charge of filling their pill boxes that are separated into AM, NOON, PM, etc.  Mark the dosage, name, quantity and what it looks like, additional instructions, what it is for, and the drug store where the prescription record is kept for refills, or whatever your regular source is.  It can be a challenge keeping all this straight if your person takes a number of medications, and if they often change.  This list is especially helpful if you suddenly get called away.  Then someone filling in for you can take over more easily.




  • 0.112 mg. Levoxyl—1 small irregular-shaped pink colored tablet before breakfast (for hypothryroid) Rx CVS drugstore.
  • .05 mg. Florinef—1/2 small white tablet (for electrolyte regulation) Rx CVS.


  • 0.125 Digoxin—1 very small yellow tablet (for heart arrhythmia) Rx CVS
  • Spirulina—1 green capsule (nutrition) from Vitamin Shoppe


  • Olive Leaf Extract—1 grey/tan herb capsule (UTI prevention) from Vitamin Shoppe




You can list all their supplements, along with the quantities, including all the different vitamins in their multi-vitamin.  This may be important if your medical professional is suggesting additional vitamins or minerals, and they need to know how much your person is already taking.  Also a doctor might want to know because some drugs interact poorly with some herbs and vitamins.


TWINLAB CALCIUM 500 TABS, 3 tablets contain:

                                                                                    % Daily Value


Vitamin D                               600 IU                         150%                                                  

    (from cholecalcifero)

Calcium                                  1500 mg.                     150%

     (from calcium carbonate)

Magnesium                             750 mg.                       189%

     (from magnesium oxide)





Keep a tabbed section where you keep the pages that you get from the pharmacy with each prescription drug that tells you what the side effects of that drug are.  You can keep them alphabetically and refer to them if your person seems to be having difficulty, especially in the first week after starting a new drug.




These are separated with tabbed dividers and they are named by each condition or system that your person gets tested for.  Many of them may correspond to the system or disease categories that you made to describe different medical difficulties on your first page.  Also include a section for Blood Tests.


Be sure that you collect the report for every test that is given, and put the most recent report at the front of the section so that they stay in chronological order.  Then every time you take your person to see any medical professional, be sure to take this book with you.  If the medical person asks about any test, you have it there for them, and if they want, their secretary can take a copy for their records.  Do not give your copies away.




Now, as you can see, you can use this style of format and apply to whatever other needs your person may have—e.g. legal interviews, records and judgments; care-giver schedules; and so on.  You can keep related material in this booklet, or you can create other booklets for different subject matter. 


The point is, you will be organized and be able to present complicated material in a very quick, complete and straight forward way to the professionals, with easy reference to all the details of backup material.  And in the process, you will stay up to date and “studied” in the information so that you can communicate well with the professionals—not emotionally!  Emotionality doesn’t carry much weight with the professionals, but facts do!  The result is that using this method will help you and your person stay in charge of the process as a working member of the care team—not a victim of it.


All my prayers are with you for this sometimes extreme job that you are taking on!  Blessings, Dear!