When I worked at the hospital, I was repeatedly told that the H & P (history and physical) was key to proper diagnosis and treatment. Having an accurate and up to date medical history can be the difference between life and death in an emergency room situation. A National Electronic Medical Records Database is essential to ensuring quality health care and should be part of our new healthcare plan.
Being the best medical historian you can be for your special needs child is paramount.
Having a child with special needs often creates a busy and stressful environment conducive to forgetting important information which is key to proper diagnosis and treatment. Keeping a journal and charting are two good ways to ensure that your child’s history is correct.
Another important consideration in keeping detailed accurate records is the unlikely event of the absence of the primary caregiver.
Parents do not have to wait for a formal diagnosis to begin keeping a record of physical and emotional abnormalities. Journaling symptoms to discuss with your pediatrician or mental healthcare provider does not need to be specifically formatted. It can be as simple as jotting down observations and dates in a plain notebook or calender or keeping a journal on your PC. In the latter, I would recommend printing out hard copies for your file in the event of a computer crash.
Once a formal diagnosis is made, I feel it important to make a weekly (or during times of medication trials, daily) entry to document your child’s progress or regression. As most parents of a special needs child are aware, symptoms and behaviors wax and wane and can soon be forgotten. I cannot stress enough the importance of daily documenting during times of medication trials. These are very hard times for the child as well as the caregiver. Recording the medication, form (brand or generic), dosage and times given, as well as any side effects is crucial. Adjustments are often made and it is key to have a point of reference.
As your child’s disorder progresses changes are inevitably going to have to be made. Sometimes the change may be in the choice of treating physician or in the addition of one. Here is where the history is most important, this is where the H & P, as you give it, will decide treatment.
Charting is very popular and useful. Psychiatrists and therapists treating school age children will give forms for your child’s teacher to fill out and return. The information is on a scale basis and requests specific information such as attention span, mood, social ability, grades as well as other important information. Always keep a copy for your file.
Keeping an accurate and up to date file for your child will make your life easier and alleviate one of the many stresses of doctor visits. Be sure to get copies of all reports, blood work, scans and other diagnostic testing for your personal file.
Remember, independence is not far away, your child will eventually grow up and move out. Having a history of medications that were effective and those that caused intolerable side effects will be helpful as they begin to maintain their own mental health management.
You can find sample forms, logs and other record keeping ideas online.
Keep it simple, but get it done. It is key to parenting the special needs child.