Organize Your Health: How to Set Up and Maintain Your Medical Records
Whether recorded on paper or online, your medical records for ADHD are important. They are a written record of your mental health, and include information on evaluations, therapy, medications and the details of your treatment plan. Keeping this information handy enables you to be proactive in working with your treatment providers.
You may think you’ll remember the details of your treatment, or that some of it isn’t so important. Besides, you know your health care provider’s office has an electronic health record on file for you—somewhere. Does anyone really care that you started taking an antidepressant medication two years ago? They will, especially if there is a need to review or change your treatment plan. You may not remember the name or dosage of a prescription you’re currently taking when a new doctor needs to prescribe something else that might not interact well with it.
“The biggest problem with any disease is that people don’t keep track of their medications carefully, so there are a lot of different updates from one chart to another and one provider note to another. It’s really difficult sometimes to figure out what patients are actually taking,” says Tanya Gurvich, PharmD, BCGP, an assistant clinical professor at the University of Southern California School of Pharmacy. “For ADHD medicine in particular, there are so many slight variations. But they all have different lengths of time they’re effective, so it’s really important to keep accurate records. That way, if changes are made to what a person is taking, they’re made in a rational way, changing something very specific about the medication they’re using—whether it’s a longer-acting medication or a different formulation of the same thing, for example.”
Having good medical records shows which treatment approaches you actually received and can help guide future changes to your treatment plan if needed.
Getting the information together
But how do you set up your medical records or the medical records for your child or another family member? One of the most important steps is deciding whether you want to store your records electronically—on your own computer or in the cloud—or as a hard copy on paper. It’s really up to you. Consider which would be easiest for you to access and keep updated, especially knowing that many people affected by ADHD struggle with managing paperwork. If you’re on your home computer regularly, it’s probably no big deal to schedule five minutes once a week to make sure your medications and most recent doctor’s visits are recorded, along with any accompanying information or copies of prescriptions. You can use a basic folder where you put documents, or a software program that is free or one that has a small monthly or annual fee.
Maybe you prefer the idea of keeping a three-ring binder with pages that have pockets into which you can slide prescription information and any printed visit summaries from your doctor after each appointment. There’s little to no cost for that, once you get it set up.
Also consider how you’ll need to use your medical records and when you’ll want to access them. If you’ll need them when you’re traveling, for example, an electronic version in the cloud might be more practical, so you can just open it up wherever in the world you find yourself. But if you’re someone who likes to be able to flip through pages and lay your hands on something, a folder or binder that you keep in a safe place is probably best. There is no right or wrong answer—the best choice is whatever works for you, and whichever option you feel most confident about keeping up-to-date.
What to include
Once you’ve settled on how and where you will organize your medical records, you need to collect the information. The US National Library of Medicine from the National Institutes of Health recommends starting with a page that lists your basic information, including name, birth date, blood type, and emergency contact information.
List any diagnoses you have received, especially any condition that may co-occur with your ADHD diagnosis. Additional physical health concerns or diagnoses should also be included with this information since symptoms or treatment plans for those conditions can affect ADHD symptoms.
Your next step is to contact the offices of any healthcare providers you have seen in the last few years. You can call, email, or write a letter. Ask the health care provider’s office to send you a list of all evaluations you’ve had, along with the dates you had them.
You will need to include all medications and supplements that are currently in your treatment plan. That includes dosages and whether you take generic or name-brand medications. A list of medications that you have taken in the past but stopped is important too, especially if you experienced a side-effect or did not receive any benefit from the medication.
From your primary care provider, you should request information on screenings for other health conditions, such as blood pressure or blood sugar readings or a test of your cholesterol levels. You’ll also want your vaccine history and to know if you’re due for any booster vaccines.
If you have been hospitalized or undergone surgery, those events should be mentioned as well.
Creating the habit of recording information
Going forward, you’ll want to get in the habit of saving the printout about your prescriptions from your pharmacy, either in a file folder or by scanning and keeping an electronic copy. You’ll also want to keep anything that your insurance company sends about your treatment and coverage. Marking a regular date on your calendar to review information is also helpful in keeping records up-to-date.
Then you just need to decide where to store your medical records—if they’re on your computer, the folder should be visible on your desktop at all times, but if you’re keeping a paper copy, choose a location that is safe but not so hidden that you forget to update your records regularly. The space where you pay bills is one possible spot, a location with other important documents, such as your insurance records or birth certificates, is another.
Resources for records: