Record Keeping & Personal Care Guidebecoming a chore that keeps you from spending time with the...

A Comprehensive Collection of Forms Including:Medical Information • Personal Contact Numbers • Emergency Information

Insurance Information • Care Giver’s Information •Organizational Tools

Record Keeping & Personal Care Guide

Why Keep Records 3

Personal Medical Information 4

Insurance Information 7

Community Resources Information 9

Care-Giver’s Guide 11

In Case of Emergency 18

Grocery List Template 21

Phone List Template 22

Personal Budget Worksheet 23

Table Of Contents

8 East Long Street,12th Floor Columbus, OH 43215

Telephone: 614-466-5205 Toll Free: 800-766-7426

TTY: 614-644-5530 FAX: 614-466-0298

www.ddc.ohio.gov

3

KEEPING VITAL RECORDS IS ESSENTIALNothing is more important to your personal welfare than developing and maintaining a complete, up-to-date record-keeping system.

Record-keeping is essential. It’s important for emergency hospital visits, insurance claims, respite care providers, or for documenting events and/or contacts about your medical needs. There is no other way to be prepared for events where current information is needed. Like it or not, understand it or not, there are forms you have to fill out everywhere you go! Having basic information on hand makes it manageable. It’s also a way of noting family history, developmental landmarks, and the next logical steps which may help identify delays or detect problems.

PERSONAL, MEDICAL & INSURANCE INFORMATIONBelow is a list of some of the important information that must be kept. It is not a complete list – that depends entirely on your disability or chronic illness. You may also decide to provide this information to other members of your family. This includes such personally identifiable information as:

Personal •Birthcertificates; •Parentorguardianinformation; •Locationofwillsand/ortrusts; •Dailycareschedule; •Grocerylist; •Budgetinformation; •Emergencycontacts;

Medical •Initialdiagnosis; •Healthhistory; •Physiciansandothermedicalspecialists; •Medicationandseizurelogs; •Dailycareschedule; •Immunizationrecords; •Officevisits; •Hospitalizationinformation; •Emergencycontacts;

Insurance •Healthandlifeinsuranceinformation;

MEDICAL BILLS & INSURANCE CLAIMSKeep all information needed to fill out forms. Keep a supply of blank claim forms, envelopes and stamps. Maintain files on all insurance company correspondence or claims. For tax purposes, keep an accurate account of what your policy covered and your out-of-pocket expenses.

EVALUATIONS, REPORTS & RECORDSKeep copies or records of all correspondence (written and verbal) with service providers, medical support specialists and other professionals your child comes in contact with, along with all reports, records and other documents. They may contain important information in those cases where discrepancies may arise concerning your needs and/or program. Be certain copies of all medical reports are sent to your physician.

GETTING ORGANIZEDHowyourrecord-keepingsystemisorganizedisuptoyou.Justbecertainitallowsquick,easyaccesstoalltheinformation needed under any set of circumstance. Here are some recommendations. Purchase a three-ring binder with pocketsfororganizingandholdingreports,etc.Insertblankpagesand/orformsforrecordingyourowninformation.Keepall current information in the notebook. Keep older information in a permanent, but portable, filing system. Purchase a small, portable file and file folders. File information using separate file folders for each category. To prevent record keeping from becomingachorethatkeepsyoufromspendingtimewiththeimportantpeopleinyourlife,organizeearlyandinamannerthat best suits your individual needs.

4

Personal Medical Information

Name Age DateofBirth

Birthplace Sex (M ) (F ) Social Security Number

Address City State Zip

Home Telephone ( ) Work Telephone ( ) Cell Phone ( )

Father/Legal Guardian Social Security Number

Address (if different) City State Zip


Mother/Legal Guardian Social Security Number



Emergency Contact Relationship


Per

son

al I

nfo

rm

atio

n

InitialDiagnosis

DiagnosisDate

Other Medical Conditions/Information

Allergies

Medications

AssistiveDevices

Eyeand/orHearingDevices

Family Physician

Office Address

City State Zip

Office Telephone ( )

Other Medical Specialist

Office Address

City State Zip



Office Address

City State Zip



Office Address

City State Zip


Hea

lth

His

tor

y

Today’sDate

5

Tes

ts &

Eva

luat

ion

s

Med

ical

Off

ice

Vis

itsConducted By

Office Telephone

DateConducted

Test/Evaluation Result

Conducted By

Office Telephone

DateConducted


Conducted By

Office Telephone

DateConducted


Conducted By

Office Telephone

DateConducted


Conducted By

Office Telephone

DateConducted


Date

Reason for Visit

Physician/Specialist

Clinic Name

Office Telephone

Test Performed

Results & Treatment

Follow-Up Instructions

Notes

Date

Reason for Visit


Clinic Name

Office Telephone

Test Performed

Results & Treatment


Notes

Date

Reason for Visit


Clinic Name

Office Telephone

Test Performed

Results & Treatment


Notes

6

Med

icat

ion

Rec

or

ds

Date Prescribed or Changed

MedicationDoseage &

Times Per DayDoctor’s Special

InstructionsSide Effectsor Concerns

DateDiscontinued

ReasonDiscontinued

7

Insurance Information













Per

son

al I

nfo

rm

atio

n

Today’sDate

Primary Insurance Carrier

Office Address City State Zip

Office Telephone ( ) Policy Number Group Number

Agent’s Name

Agent’s Address City State Zip


Secondary Insurance Carrier



Agent’s Name



MedicaidNumber State DateofEligibility

Insu

ran

ce

Co

mpa

ny

Info

rm

atio

n

8

Po

lic

yho

lder Name


Home Telephone ( ) Cell Phone ( )

DateofBirth SocialSecurityNumber

Fam

ily

Mem

ber

s Name Relationship to Policyholder


Name Relationship to Policyholder


Name Relationship to Policyholder


Oth

er I

mpo

rtan

t In

for

mat

ion Pre-existing conditions not covered, waivers or riders attached to the policy, cost-share information, etc.

9

Community Resources Information













Per

son

al I

nfo

rm

atio

n

Today’sDate

NameofAgency/Organization


Office Telephone ( ) Contact Person

DescriptionofServices





Co

mm

un

ity

Serv

ices

(N

on

pro

fit)

10









Co

un

ty

Serv

ices









Oth

er A

gen

cy/

Or

gan

izat

ion









Stat

e A

gen

cy/

Or

gan

izat

ion

11

Care-Giver’s Guide

Child’sName Age DateofBirth












Per

son

al I

nfo

rm

atio

n

Today’sDate

Police, Fire & Ambulance – 911Poison Control Center Telephone ( )

Family Physician Telephone ( )

Pharmacy Telephone ( )

Insurance Agency

Contact Person Telephone ( )

Preferred Hospital Telephone ( )

Neighbor Telephone ( )

Neighbor Telephone ( )

Relative or Close Friend

Relationship Telephone ( )

Relative or Close Friend

Relationship Telephone ( )

Emer

gen

cy

Co

nta

cts

/Nu

mbe

rs

12

First aid kit location

Who, if anyone is allowed to visit the child when the parent isn’t home?

Is the child allowed to play outside? (Yes) (No)

If so, explain the boundaries, rules and length of time

Household rules providers and caregivers should follow when the parents are not home

Ho

use

ho

ld R

ou

tin

e

7:00 AM

8:00 AM

9:00 AM

10:00 AM

11:00 AM

12:00 PM

1:00 PM

2:00 PM

3:00 PM

4:00 PM

5:00 PM

6:00 PM

7:00 PM

8:00 PM

9:00 PM

10:00 PM

11:00 PM

12:00 AM

1:00 AM

2:00 AM

3:00 AM

4:00 AM

5:00 AM

6:00 AM

Ch

ild

’s D

aily

Sc

hed

ule

13

ChildDiagnosedWith

Other Medical Conditions/Information

Family Physician



Allergies

Ch

ild

’s M

edic

al I

nfo

rm

atio

nC

hil

d’s

Med

icat

ion

s

Medication Doseage Time(s) GivenPrescribing

DoctorEmergencyTelephone

14

Doesthechildhaveseizures?(Yes)(No)

If so, describe in detail

Generallengthofseizures

Whatprocedure(s)shouldbefollowedduringaseizure?(Doyouwanttheparamedicstobecalled?)

Shouldseizuresberecorded?(Yes)(No)

Whatusuallyoccursfollowingaseizure?(Willthechildbecomesleepy,cranky,etc.)

Seiz

ur

es

Describethechild’snormalbehavior

Are there behaviors that are particularly challenging?

If so, what actions should be taken?

Is there a specific behavior plan for the child? If so, please describe

Has the child been known to wander or run away?

Activities that make the child happy, including toys, favorite games, etc.

Notes

Ch

ild

’s B

ehav

ior

15

Is the child verbal? (Yes) (No)

In case the child isn’t verbal, how does he or she communicate?

Specifically, how does the child communicate the need to eat?

Ask to be picked up or held?

Express interest in playing with a specific toy or game?

Doesthechildusesignlanguageasaformofcommunication?(Yes)(No)

If so, please explain how

How does the child communicate the following?

Co

mm

un

icat

ing

Wit

h T

he

Ch

ild

Hungry

Thirsty

Tired

Happy

Hot

Cold

Brother

Sister

Mother

Father

Blanket

Bath

Toilet

Diaper

Bed

Dog

Cat

Video

TV

Music

Hello

Goodbye

Car

Walk

Outside

Inside

Sad

Angry

Play with me

Leave me alone

I want more

I am finished

Please

Thank you

I’m sick

Other

16

Doesthechilduseaspecializedcommunicationdevice?(Yes)(No)

If so, explain how the device is used

Where is it located and/or placed when not in use?

Co

nt.

..

Are there foods the child likes?

Are there foods the child dislikes?

Doesthechildhaveanyfoodallergies?Ifso,pleaselistandidentifysymptoms

Doesthechildswallowwell?(Yes)(No)Pleaseexplain

Doesthechildneedassistancewhileeating?(Yes)(No)Ifyes,whattypeofassistanceisnecessary?

Isthereaparticularpositionoradaptiveequipmentnecessarytoassistthechildduringthemeal?

Pleasedetailthelocationofthechild’sfood,eatingutensilsand/oradaptiveequipment

Ch

ild

’s D

iet

At what time does the child go to bed?

What are the child’s nap time(s)?

Doesthechildsleepalone?(Yes)(No)

Is the child afraid of the dark? (Yes) (No)

Is there a special toy or blanket the child likes to sleep with?

Are there special positioning needs at bed time?

Is any special nightly routine observed?

Doesthechildusuallysleepthroughthenight?(Yes)(No)Ifnot,explaintheactivitiesrequiredtoeitherinducesleeporkeep

the child occupied while awake.

Ch

ild

’s B

ed &

Nap

Tim

es

17

Doesthechildusethetoilet?(Yes)(No)

Can he or she use the toilet alone? (Yes) (No)

Ifnot,describethespecialassistancerequired

Doesthechildrequirediapers?(Yes)(No)

Training Pants (Yes) (No)

Use a potty chair? (Yes) (No)

Can the child brush his or her own teeth? (Yes) (No)

If yes, explain how

Can the child dress himself or herself? (Yes) (No)

If yes, what assistance is necessary?

Can the child bathe himself or herself? (Yes) (No)

Isadaptiveequipmentrequired?(Yes)(No)

Ifyes,explainhowtheequipmentisused

Per

son

al H

ygie

ne

Doesthechilduseadaptiveequipment?(Yes)(No)

Describetheequipmentandhowitshouldbeused

Ad

apti

ve/

Ass

isti

ve

Equ

ipm

ent

18

In Case Of Emergency

Child’sName Age DateofBirth




Height Weight

Hair Color Eye Color

DistinguishingMarks

Per

son

al I

nfo

rm

atio

n







Primary Emergency Contact Relationship


Today’sDate

Emer

gen

cy

Co

nta

ct

Nu

mbe

rs

Secondary Emergency Contact Relationship


Primary Physician

Office Telephone ( ) Emergency Telephone ( )

Notes

Secondary Physician

Office Telephone ( ) Emergency Telephone ( )

Notes

What I want an emergency physician to know

19

Pres

cr

ipti

on

Dr

ug

sA

ller

gie

sC

hr

on

ic C

on

dit

ion

sMedication Doseage Frequency Reason

Type Severity Frequency/Last Occurrence

Type Severity Notes

20

Primary Insurance Carrier



Agent’s Name



Secondary Insurance Carrier



Agent’s Name



MedicaidNumber State DateofEligibility

Insu

ran

ce

Info

rm

atio

nN

ote

s

21

Grocery List

Make grocery shopping easier by always going with a prepared list. The following template can be copied and used again and again.

ProducePotatoesMushroomsOnionsLettuceTomatoCarrotsBroccoliCauliflowerSpinachBananasApplesOrangesGrapesMelonBerriesLemon/Lime__________________

DeliDeliMeatsDeliSaladsDeliCheese__________________

SnacksCookiesCrackersGraham CrackersChipsPopcorn__________________

BreadsBreadHotDogBunsHamburger BunsBagelsEnglish MuffinsCroutons__________________

BeveragesJuiceKool AidLemonadePop/SodaBottled WaterChocolate SyrupCoffeeTea__________________

CondimentsBBQ SauceMustardMayonnaisePickles/RelishKetchupMarinadeSaladDressingsJelly/JamPeanut ButterSeasoning Packet__________________

Canned GoodsTunaSpaghetti SaucePizzaSauceTomato ProductsMushroomsSoupBeansCorn__________________

Canned FruitsApplesauceFruit CupsPineapplePeachesPearsFruit CocktailRaisins__________________

BakeryDonutsCakePieCinnamon RollsBrowniesCookies__________________

DairyMilkOrangeJuiceDinnerRollDoughCookieDoughButter/MargarineEggsYogurtSliced/Shredded CheeseCream CheeseSour CreamCottage Cheese__________________

CerealsCerealGranola BarsOatmealHot Cereal__________________

PastaSpaghettiMac & CheeseLasagna NoodlesRiceNoodle & Sauce Mix__________________

Ethnic FoodsTaco MixTortilla ShellsTaco SauceSoy SauceTeriyaki Sauce__________________

MeatGround BeefChickenGround TurkeyBeef RoastSteaksBurger PattiesPork ChopsPork RoastBaconHotDogsSausageBratsHam__________________

BakingSugarFlourPancake MixMuffin MixCake/Brownie MixPie CrustMarshmallowsJelloPuddingPancake SyrupHoneyChocolate Chips__________________

Health/BeautySuntan lotionShampooConditionerDeodorantBath SoapFeminine SuppliesMake-UpToothpasteMouthwashLotionBand AidsAntiseptic CreamMedicinesVitamins__________________

Frozen FoodsFrozenMeatsFrozenVeggiesFrozenFruitsWafflesFrench FriesPizzaIce Cream__________________

Paper GoodsNapkinsPaper TowelsToilet PaperTissuesPaper PlatesPaper CupsPlastic BagsAluminum FoilPlastic WrapWax Paper__________________

CleanersLaundryDetergentFabric SoftenerDishwasherSoapBleachDisinfectantDustingSpray__________________

Baby ItemsBaby FoodDiapersBaby Wipes__________________

OtherPet FoodLight BulbsCards/Gift Wrap__________________

22

Phone List

My Home Telephone

My Cell Phone

Mother/Guardian

Father/Guardian

Primary Physician

Secondary Physician

Dentist

Optometrist

Neighbor

Neighbor

Babysitter

Impo

rtan

t Ph

on

e N

um

ber

s

23

Personal Budget Worksheet

Income Monthly Amount

Net Pay

SecondJob-NetPay

Investments

Interest

Other

TOTAL INCOME $ .

Inc

om

e

Expense Monthly Amount

Cable TV

Car Payments

Child Care

Credit Card Payments

Insurance (Health, Life, Property)

Internet Service Provider

Rent or Mortgage

Student Loans

Taxes

Telephone

Utilities

Other

TOTAL ROUTINE EXPENSES $ .

Ro

uti

ne

(Fix

ed)

Exp

ense

s

Expense Monthly Amount

Babysitting

Food

Transportation (Gas, Maintenance, Parking, Taxis)

Vacation

Clothing(Purchases,DryCleaning)

Education

Entertainment

Gifts (Birthdays, Holidays, Weddings)

Hair Care, Body Care (Hair Cuts, Manicures, Tanning)

Medication, Medical Visits, Glasses/Contacts

Savings

Other

TOTAL VARIABLE EXPENSES $ .

Var

iabl

e Exp

ense

s

Total monthly fixed and variable expenses $ . Differencebetweenmonthlyincomeandexpenses=surplus/(deficit) $.

It is the mission of the Ohio Developmental Disabilities Council to create change that improves independence, productivity, and inclusion for people

with developmental disabilities and their families in community life.

www.ddc.ohio.gov

Record Keeping & Personal Care Guidebecoming a chore that keeps you from spending time with the...

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