Medical History Template

I've had numerous medical professionals comment on how much easier their job is when I hand them Aaron's medical history.  I've designed it so that the most important information is on the front page.  This would be anything needed to treat in an emergency, like current diagnosis, medications, weight, and so on.  Then it goes back in decreasing order of importance.  I put the template here in case anyone else finds it helpful.  It's been a work in progress, so feel free to adapt as you need to.  The best part about it is, all the important information is there, so I don't have to remember it when I'm already stressed.

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Page 1 -- this is the most important page

Name                                                               MEDICAL ACTION (full code, dnr, no cpr, whatever)

In this text box put:
Insurance Co & policy #
Date of birth
EGA (gestational age @ birth)
Birth weight & blood type
Current weight & date last weighed
Medical Allergies
Immunization status

Other important issues:
Trach size, vent settings
g-tube size, etc that would
be needed ASAP in an
emergency.

123 Main St

Anytown, ST 00000

Dad & Mom’s names

123-456-7890 hm

123-456-7890 cell

Current Diagnosis

(list in descending order of importance)

Trisomy 18

Cardiac issue

Pulmo issue

Etc.

Chronic cuteness

Current Meds

(medication & strength)                                    amnt & freq                                   

Oxygen (yes, it’s a med)                                    continuous

Sildenafil 2.5 mg/ml                                           2.5 ml q 6 hr

Discontinued Meds

(same set-up as current meds but w/ dates and reason)

Septra                                                             3.0 ml bid m/d-m/d/yy UTI

Ciprofloxin 100mg/ml                                    .75 ml bid 

m/d-m/d/yy

 pneumonia

  

                                                                       1.5 ml bid 

m/d-m/d/yy

 tracheitis

 

Create text box w/ feeding info
formula, feeding sched, &
24 hr total.

 ************************************

Page 2 (and so forth as needed to cover the history)

Current Physicians & Providers

(primary care first, then down in order of importance)

Best Doctor, MD  pediatrician

357 S. Center St

Anytown, ST  00000

987-654-3210

987-654-1230 fax

In-home nursing

987-456-1230

MD  cardiologist

phone

MD pumonologist

phone

MD  urologist

phone

MD  geneticist

phone

Early Intervention

phone

OT  phone

PT phone

wheelchair shop

phone – contact name

Home Health Equipment 

(include after hours emergency #)

Company name, phone 

Oxygen (what they provide)

Company name, phone

Trach/Vent, O2 monitor, feeding supplies (what they provide)

Pharmacies

Name of pharmacy

Phone number

Fax number

Hospitalizations

(list most recent first)

Dates admitted

Hosptial

Dx:                 

Rx:                 

Procedures done, other pertinent info.  Try to keep it short.

mm/dd-mm/dd/yyyy

PCMC

Dx:                  Tracheitis pseudomonas, eye infx

Rx:                  Cirpo 5g/100ml 1.5 ml bid for 10 days

2/18-2/24/2011

PCMC

Dx:                  Psuedomonas pneumonia

Rx:                  Cipro 100mg/ml  0.75 ml bid,  Inc tidal volume 70, 1 ml air in cuffed trach

                  Synagis m/d/yy

mm/dd-mm/dd/yyyy

PCMC

G-tube, Nissen, Tympanostomy, Bronchosope m/d/yy

Tracheostomy m/d/yy

Ventilator settings

18 bpm

50 tidal volume

0.3 sec/I time

13 pressure support

8 PEEP

Alarm 45 high, 5 low pressure

Sensitivity 2

Limited echo m/d normal cardiac function, PHT not measured

Discharge:  Inc Previcid from 1.0 ml to 1.33 ml daily.

mm/dd-mm/dd/yyyy

PCMC                 

Dx:                  Hypoxia

                  Aspiration

                  Pulmonary hypertension

                  CHF

                  VSD

NJ tube placement – 44 cm nose to hub.  24 kcal breastmilk/formula.  456 ml@22ml/hr over 24 hours

Mm/dd-mm/dd/yyyy (in this case, since it’s NICU, from date of birth to discharge)

UVRMC  NICU

Dx:                  Trisomy 18

Respiratory insufficiency

Mild pulmonary hypertension

VSD

Dysplastic tricuspid valve

Rx:                  Poly-vi-flor w/ iron .05 ml/daily

                  O2 ¼ l/min

Doctor’s Visits

(again list most recent first, record provider visits & telephone calls)

Date                 Dr. (full name)                 Notes(try to keep to 1-3 lines, very brief overview)

5/9/11               T/C cardio                Inc sildenafil to 2.5 ml q 6 hr based on new weight.

5/6/11               Dr. K                        Weight check – 5.9kg; inc feeds to 720 ml/day, prevcid to 2ml

5/4/11               T/C Dr K                  HUGE desat (33%), order labs/x-ray @ Riverton.  X-ray good, 

                                                                  most labs good, WBC 19,000.  Rx cipro1.5 bid for 10 days.

5/2/11               N H, AUD                 ABR test shows almost no hearing, but responds to aud stimuli    

                                                                  with movement and inc heart rate.  Refer to School for 

                                                                  Blind and Deaf for PIP EI.

3/29/11             Shriners                    Ortho consult. Splints for hands, 4-5 hr for thumb, sleeping for

                                                                   resting splints.  Spine okay.  Club foot clinic in June

3/25/11             Dr. K                         9 mo check up.  Looks great!  Last Hep B & Synergis shot

                                                                   24 ½ inch, 12# 1oz, head circ 40.9cm, labs in 1 month

3/9/11               Trach/vent clinic       Increase feeds.  Keep 1ml air in cuff.  Place trach when

inhaling.  Check ear tubes during lip repair & do ABR.  Lower brady setting to 60.  2^nd flu shot.  Rx:  Tramcinolone acetnide bid prn for g-tube

Early Intervention or other Therapies

(use same format as dr visits)

4/1/11                 OT                             Use ball for stretching.  Lie down on lap for tummy time.

3/23/11               OT                             Work on standing muscles. Stretch hands.  Sitting. Reaching

                                                                          for

 objects, swinging in a blanket.

2/8/11                 Hearing test               Referred both ears.  Need ABR

10/8/10               OT                              Use yoga ball for strength training.  Cellophane as

visual/auditory stimulation.  Keep stretching hands

8/27/10               self decision                Suspend use of bottle & oral feeds.  Much fussier, gagging,

vomiting after feeds, mult desats.  Wonder if, although he can protect his airways, if he gets “tired” & it’s too hard.  Will try again starting next Tuesday.

8/31/10               self decision                Discontinue bottle indefinitely after call to Dr. K.

Outpatient Studies                 

(studies/labs done on an outpatient basis – same format as dr visit)

7/30/2010           PCMC                        Echo

8/17/2010           PCMC-Riverton        Swallow study

9/8/2010             AFH                           Hearing screen DPOAE

*Use footer to date each time you update so you know how recent info is.

*Use abbreviations common to your area to save space – i.e. in Utah, everyone knows that PCMC is

Primary Children’s Medical Center and UVRMC is Utah Valley Regional Medical Center.

*Make changes you need to make this work for you.  It is not a Bible.  It is a work in progress.